ACE-E Section 504-ADA Guidelines Forms


S 504/ADA Guidelines & Forms


Introduction ……………………………………………… 1


Acronyms/Definitions ………………………………….. 2


Overview …………………………………………………. 8


Summary of Subparts ……………………………………. 8


Eligibility …………………………………………………. 11


Equal Educational Opportunities ……………………… 13


Examples of Discrimination ……………………………  16


Forms …………………………………………….………   17


Annual Notice (Form A) .………………………………   18


Information for Parents (Form B) …………………….   19


Evaluation Procedures (Form C) ……………………..   20


Parent/Student Rights (Form D) …………………….    21


Consent …………………………………………………     23


Referral (Form E) ………………………………………    24


Initial Notice to Parents (Form F) ……………………    25


Student Accommodation Plan (Form G) …………..      .    26


Review of Services (Form H) ….……………………….  28


Checklist …………………………………………………   29


Individualized Health Care Plan (Form I) ……………  30


Emergency Care Plan (Form J) ……………………….    31


OCR Complaint Process (Form K) ……………………  32





The purpose of these guidelines is to provide guidance to school staff regarding

obligations under Section 504 of the Vocational Rehabilitation Act. These same

obligations are required by Title II of the Americans with Disabilities Act (ADA).



Section 504 was implemented to prevent discrimination against individuals with

disabilities in federally funded programs. Section 504 of the Rehabilitation Act was

enacted in 1973. These federal regulations were implemented in 1977, and have seven sections: 

Subpart A         General Provisions

Subpart B         Employment Practices

Subpart C         Program Accessibility

Subpart D        Preschool, Elementary, and Secondary Education Requirements

Subpart E         Postsecondary Education Requirements

Subpart F         Health, Welfare, and Social Services

Subpart G        Procedures


These guidelines reference Subparts A, B, C and D of the Section 504 regulations regarding student issues.

"Handicapped individuals" will hereafter be referred to as “individuals with

disabilities" in order to be consistent with current educational terminology.

For many years, the main area of enforcement of Section 504 has been employment

issues for individuals with disabilities. However, within the last several years, the

Office for Civil Rights (OCR) has become more active in the provisions of Section 504 regarding the education of students with disabilities.



The 504 statute prohibits discrimination against any individuals with disabilities by

public schools receiving federal financial assistance.



Section 504 is a general education management responsibility.




The following are commonly used acronyms and definitions used in Section

504/ADA and special education:


ADA — Americans with Disabilities Act

ADAAG — Americans with Disabilities Act Accessibility Guidelines

ADD — Attention Deficit Disorder

ADHD — Attention Deficit Hyperactivity Disorder

AG — Annual Goal

AP — Accommodation Plan

APR — Annual Performance Report

AYP — Annual Yearly Progress

BIE — Bureau of Indian Education

CD — Cognitive Delay

CFR — Code of Federal Regulations

CIMFS — Continuous Improvement Focused Monitoring System

DD — Developmental Disabilities

DNR — Do Not Resuscitate

DOE — Department of Education

ED — Emotionally Disturbed

EI — Early Intervening

ESY — Extended School Year

FAPE — Free Appropriate Public Education

FERPA — Family Educational Rights and Privacy Act

HI — Hearing Impaired

IDEA — Individuals with Disabilities Education Act—Special Education (2004)                                                                                               -2-

IEP — Individualized Education Program

IFSP — Individualized Family Service Plan

LEA — Local Education Agency

LRE — Least Restrictive Environment

LD — Learning Disability

MPRRC — Mountain Plains Regional Resource Center

NCLBA — No Child Left Behind Act

OCR — Office for Civil Rights

OHI — Other Health Impaired

OSEP — Office of Special Education Programs                             

OT — Occupational Therapy

Part B — Special Education for School-Aged Students

Part C — Special Education for Infants and Toddlers Birth through Two Years

PT — Physical Therapy

RtI—Responsiveness to Intervention

SEA — State Education Agency

Section 619 — Special Education for Three to Five Year Olds

SPP — State Performance Plan

RtI — Responsiveness to Intervention

TTY — A Telecommunication Device for the Deaf (Teletypewriter)

VI — Visually Impaired

504 — Section 504 of the Rehabilitation Act






The following are definitions that will be used in this manual.


ACCOMMODATIONS—Adaptations made by classroom teacher(s) and other school staff to enable the students to benefit from their educational program. In some cases, a Section 504 plan should be developed outlining accommodations.


ADA ACCESSIBILITY GUIDELINES (ADAAG)—Standards used to meet Section504/ADA accessibility requirements for the design, construction, and alteration of buildings.


AMERICANS WITH DISABILITIES ACT (ADA)—A civil rights law that prohibits discrimination against persons with disabilities in the areas of accessibility,

employment, public services, public accommodations, transportation, and



BARRIER-FREE ENVIRONMENT—A school environment that contains no obstacles to accessibility and usability by students and other individuals with disabilities. Barriers can be physical and nonphysical.


CONSENT — Written parent permission before initial evaluation and initial

education placement.


CONTAGIOUS DISEASES PROTECTED UNDER 504—Contagious diseases are those that can be transmitted from person to person. Examples are diseases such as AIDS, HIV, and tuberculosis.


EARLY INTERVENING—A group of school staff knowledgeable about the student who work together recommending accommodations to help the student succeed in his/her general education program. This is sometimes referred to as a pre-referral process. Every effort should be made to keep the student in the general education program. A referral is made for an evaluation after all efforts have failed.


FAMILY EDUCATIONAL RIGHTS AND PRIVACY ACT (FERPA)—The federal law and regulations that address student record keeping and confidentiality.


FREE APPROPRIATE PUBLIC EDUCATION (FAPE)—Related aids and services that are designed to meet individual educational needs of students with disabilities as adequately as the needs of non-disabled persons are met.



(IDEIA) 2004—Federal special education law and regulations.                                     



MAJOR LIFE ACTIVITY—Functions such as caring for one’s self, walking, seeing, hearing, speaking, breathing, learning, and working.  General functions include: lifting, bending, sleeping, reading, concentrating, thinking, communicating, and eating.  Major bodily functions include: the immune system, digestion, bowel, bladder, respiratory, cell growth, neurological, brain, circulatory, endocrine, and reproductive functions. 


OFFICE FOR CIVIL RIGHTS (OCR)—This federal agency has three primary

responsibilities: investigating complaints, conducting compliance reviews, and

providing technical assistance. There are 10 regional offices located throughout the

United States.


PHYSICAL OR MENTAL IMPAIRMENT—(1) any physiological disorder or

condition, cosmetic disfigurement, or anatomical loss affecting one or more of the

following body systems: neurological; musculoskeletal; special sense organs;

respiratory, including speech organs; cardiovascular; reproductive; digestive;

genitourinary; hemic and lymphatic; skin; and endocrine; or (2) any mental or physical disorder, such as mental retardation, organic brain syndrome, emotional or mental illness, and specific learning disabilities.


The term “physical or mental impairment” includes, but is not limited to, such diseases and conditions as orthopedic, visual, speech, and hearing impairments;

cerebral palsy; epilepsy; muscular dystrophy; multiple sclerosis; cancer; heart disease; diabetes; mental retardation; emotional illness; drug addiction; and alcoholism.


PROGRAM ACCESSIBILITY—The school will ensure programs and activities are

accessible to and usable by persons with disabilities. In many instances, programs and activities may be made accessible through slight modifications and adjustments in procedures, practices, and policies. In others, building renovation or construction may be required. Structural change is required only where program accessibility cannot be achieved effectively through other means.


PROGRAM OR ACTIVITY—In the context of Section 504/ADA, this includes all

operations of State and local agencies that receive federal funds. This includes colleges, universities, and/or school districts.


PUBLIC ENTITY—Any school, organization, agency, or office that receives federal

funding and is therefore, obligated to follow Section 504/ADA requirements.


PUBLIC NOTICE—The school is required to provide public notice and internal notice (i.e., to staff, individuals with disabilities, and students) stating it does not discriminate on the basis of a disability.




QUALIFIED STUDENT—Any student who has a physical or mental impairment that substantially limits one or more major life activities and impacts education.


RESPONSIVENESS TO INTERVENTION (RtI)—Usually a three tiered process that begins with classroom interventions and progresses to special education. Section 504 is found in tier two of the process.


SECTION 504—The Vocational Rehabilitation Act of 1973 that guarantees specific

rights in federally funded programs and activities to people who qualify as disabled.

Section 504 states, “No otherwise qualified disabled individual in the United States...

shall, solely by reason of a disability be excluded from the participation in, be denied

the benefits of, or be subjected to discrimination under any program or activity

receiving federal financial assistance.”


SECTION 504/ADA COORDINATOR—The school employing 15 or more persons must assign a person to coordinate compliance with Section 504 regulations. It is recommended that all schools appoint a 504/ADA coordinator. It is recommended that the same individual serve as the Americans with Disabilities Act Coordinator and be a general educator.


SECTION 504 CASE MANAGER—This is usually the primary school staff member providing accommodations for a specific student. Case managers could include counselors, school nurses, and general education teachers. The case manager maintains the Section 504 student file.


SELF-EVALUATION—The Americans with Disabilities Act requires that federal fund recipients evaluate their programs, physical accessibility, and employment practices to determine the extent to which programs and activities require modification to ensure full participation by students with disabilities. These evaluations should be revisited annually by the Section 504/ADA Coordinator.


TITLE I (NCLBA)—Provides financial assistance to States and eligible agencies to

deliver supplemental services to at-risk students.


TRANSITION PLAN—If a school determines that structural modifications are

necessary to meet Section 504/ADA program accessibility requirements, the school

must develop a plan specifying the steps necessary to complete such changes and the

time frame for completion.










Section 504/ADA is a civil rights statute aimed at discrimination against individuals

with disabilities. Like other statutes of Title VI (race) and Title IX (gender), Section

504/ADA focuses on discrimination based on disability. All programs or activities of

the school are covered by Section 504/ADA obligations.


There is no State or federal funding provided to assist in complying with Section 504. All costs are the obligation of the general school budget. Many schools have

established a Section 504 line item in their general fund budget to cover necessary

accommodations for individuals with disabilities.




Section 504 regulations have several areas that are particularly important for schools:

Subpart B—employment practices, Subpart C—program accessibility, and Subparts D and E—requirements for preschool, elementary, secondary, and postsecondary






This part of the regulations outlines the nondiscriminatory responsibilities of schools

that receive federal funds or are a public entity. No person, on the basis of a disability, shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program that benefits from federal funding or is a public entity.




No qualified person shall, on the basis of his/her disability, be subjected to

discrimination in employment by any program or activity that receives federal funds or is a public entity. The school must make reasonable accommodations for employees with known physical and mental impairments unless the accommodation would impose an undue hardship on the operation of the school’s program. Examples of reasonable accommodations would include making facilities accessible to and usable by persons with disabilities, job restructuring, part-time or modified work schedules, and acquisition or modification of equipment or devices.





No individual with a disability shall be denied the benefits of, be excluded from

participation in, or be otherwise subjected to discrimination under any program or

activity because facilities are inaccessible or unusable. Building and program

accessibility is applicable to any individual with disabilities accessing any activities or

programs in that school building.


The regulation contains two standards to be used in determining whether programs

and activities are accessible to individuals with disabilities. One standard deals with

“existing” facilities; the other deals with “new” construction. The term “existing

facility” means the facility was in existence or in the process of construction before June 3, 1977, the effective date of the regulation. The term “new construction” means groundbreaking that took place on or after the effective date of the regulation.

 Leased facilities (mobile units) that are leased or constructed with federal funds are required

to meet the standards of new construction. Other leased units are required to meet the

standards of existing facilities.

The standard for a facility existing before June 3, 1977, for 504 or January 26, 1992, for ADA requires that federally assisted programs or activities operated in that facility must, when viewed in their entirety, be readily accessible. This standard does not require that every facility or part be accessible so long as the program or activity as a whole is accessible. Thus, recipients need not make structural changes to facilities that existed before June 3, 1977 for 504 or before January 26,1992, for ADA where other alternative methods are effective in making programs and activities accessible so long as priority consideration is given to offering the services in the most integrated setting appropriate.


One example of an alternative method in a school would be the relocation of classes,

activities, or services to an accessible site. Facility alteration or new construction is

required to achieve program accessibility only if sufficient relocation of classes,

activities, or services cannot be housed in an existing facility. In meeting the objective of program accessibility, the school must take precautions not to isolate or concentrate students with disabilities in settings away from students without disabilities.


The regulation requires that all new construction begun after June 3, 1977, for 504 or

January 26, 1992, for ADA, as well as alterations to existing facilities, must be designed and constructed so as to make facilities accessible and usable by individuals

with disabilities.








Wyoming preschool, elementary, middle level/junior high, and secondary programs must take into account the needs of qualified persons with disabilities in determining the aid, benefits, or services to be provided under these programs or activities.


The school must provide a free appropriate public education to students with

disabilities in its jurisdiction who are eligible under Section 504/ADA. Instruction must be individually designed to meet the needs of those students as adequately as the needs of students without disabilities. This standard of what is “appropriate” differs from the IDEA “appropriate” standard, which requires the school to design a program reasonably calculated to confer educational benefit. An appropriate education under Section 504/ADA requires that the services be effective and fair.


Although Section 504/ADA does not require schools to develop an Individual

Education Program with annual goals, it is required that the school provide written

documentation for each student eligible under Section 504/ADA. If the Teacher

Assistance Team (pre-referral) suspects a need for accommodation, a referral should be made, evaluations conducted, and possible eligibility determined by a team

knowledgeable about the student. If the student is eligible, the team might develop a

Section 504 Accommodation Plan.


The quality of educational services provided to individuals with disabilities must be

equivalent to the services provided to individuals without disabilities. Teachers,

administrators, staff, and parents should receive ongoing training in the instruction of

individuals with disabilities and be knowledgeable about the disability, appropriate

materials, and equipment. The Section 504/ADA Coordinator will be responsible to develop and implement staff and parent training.




It must be emphasized that Section 504/ADA falls under the management of general education. The figure on the next page illustrates some obligations of general education under Section 504/ADA and their relationship with school personnel roles. The school staff and parents should collaborate to help guarantee that students are provided accommodations through general education. The exception to this standard is a student who has been determined eligible as having a disability under the Individuals with Disabilities Education Act (IDEA). Such a student could receive special education services under IDEA and accommodations required under Section 504/ADA. Many schools will include the Section 504 accommodations on the IEP rather than developing two separate documents.






The following is the eligibility criteria for a student to receive accommodations under Section 504.



 A person may be considered disabled under the definition of Section 504/ADA if the individual meets the following requirements:


“Major life activities” include functions such as:

Caring for one’s self

Performing manual tasks
















Immune system#





Cell Growth#





Reproductive functions#


The disability must impact the student’s education.


* = General

# = Major bodily functions

2. Has a record of such an impairment.

3. Is regarded as having such an impairment.


The second and third prongs of the definition only become a factor if discrimination has occurred because of the “record” or “history” or is regarded as having an impairment.





If the school has reason to suspect that because of a disability, a student needs special

accommodations in the general educational environment in order to have equally

effective participation in the school program, the school must notify the parent of an

individual evaluation, evaluate the student, and develop and implement a plan for the delivery of all necessary educational accommodations.


Requirements for the evaluation and placement process are determined by the type of

disability suspected and the type of services needed by the student. The evaluation

must be sufficient to assess the nature and extent of the educational impact of the

disability so that appropriate educational services can be determined. The team

knowledgeable about the student makes the decision based on evaluation data.

Identification of services needed must be made by a group of persons knowledgeable

about the student.


Decisions about Section 504/ADA eligibility must be documented in the student’s

Section 504/ADA file and reviewed at least yearly and whenever any member of the

team feels it is necessary. A case manager should be assigned to complete and manage each Section 504/ADA student file. A student’s program must be provided in the least restrictive environment, most likely the general education classroom.


Under Section 504/ADA, parents or guardians must be provided with notice of any

action that changes the identification, evaluation program, or placement of their

student. Written consent would be considered a best practice. The parents should be

included in the evaluation, eligibility, and placement process. Parents or guardians

have the right to file a grievance, request mediation, ask for a due process hearing, or

call the Office for Civil Rights if they disagree with the school.


— Best Practice —

Parent participation should always be encouraged

throughout the Section 504/ADA process.



















This regulation is limited to Section 504 of the Rehabilitation Act of 1973 as amended.  In addition, parents and students are protected by Title II of the Americans with Disabilities Act of 1990 against discrimination by the District, a public entity. 


Under Section 504, “handicapped persons” means any person who (1) has a physical or mental impairment which substantially limits one or more major life activities, (2) has a record of such impairment, or (3) is regarded as having such an impairment.  “Major life activities” means functions such as caring for one’s self, performing manual tasks, talking, seeing, hearing, speaking, breathing, learning, or working. 


As the school district attempts to remain in compliance with all applicable laws, specifically Section 504 of the Rehabilitation Act, Sublette County School District No. 9 will review students who fit in the following categories and who do not qualify under special education for possible modifications so they may equally benefit from education. 


Students with a high profile medical background:  These students have current medical concerns that may interfere with their daily performance in school.  Examples:  severe asthmatics, diabetics, severe allergic students. 


Students with a high profile of behavioral problems:  These are students who have been referred for discipline issues and who have substantial evidence of non-compliant behavior.  This behavior has required action by the school in some form or another which exceeds usual disciplinary action.  Interventions attempted within the school have not been effective. 


Students with a known high profile of chemical problems:  These are students who have been, are known to be, or suspected of being chemically dependent students.  This behavior interferes with their education process. 


Students returning to school after intensive medical treatment in a hospital or treatment center.  These students will most likely have a DSM diagnosis and due to their hospitalization or long-term treatment would require the District to be aware of them and consider modifications in educational programming. 


Temporarily disabled students:  These students may require alternative educational programming due to short-term situations that would qualify them for services.  For example, the student may be unable to get around school or may have  lost a function that is necessary to participate in class (loss of voice, eyesight, hearing, etc.).  Due to the short duration, the student may not qualify for services under IDEA.  Students who are not disabled may be provided a health care plan. 


Students who are being considered for retention. 


Students who show a pattern of not benefitting from classroom instruction. 


Students who have been identified as having attention deficit disorder. 




Students who are identified as “at risk” or exhibit the potential for dropping out of school. 


Students with a learning disability or other disability who do not qualify for special education services but who may need accommodations to reasonably and appropriately access and benefit from the educational programs and activities of Sublette County School District No. 9. 


This list of students is not exhaustive.  Each student and/or situation will be reviewed on an individual basis. 


Compliance Issues


(1)     The Superintendent or designee will act as coordinator. 


(2)    The following are responsibilities regarding student issues: 


·         Publish an annual notice and conduct child-find activities

·         Place an annual notice in student handbooks

·         Follow procedures for giving notice to parents upon referral, evaluation, and placement

·         Keep required documentation and follow district procedures regarding referrals, evaluations, placement and parent access to records

·         Coordinate both referrals and programs

·         Provide least restrictive environmental programs and placements. 


(3)    Referrals

·         Referrals may be made by parent/guardian or school official

·         A referral should be considered if the student is referred to special education and found ineligible.  However, such students will qualify only if they are handicapped under the definitions of this regulation. 

·         Evaluation must include aspects that would support the clause of “substantially limits one or more major life activity”. 


(4)    Evaluation

·         Determine what information is needed and who will be responsible

·         Parents must be notified of how to initiate a referral/evaluation

·         Parents must be provided notice of due process rights and of identification, evaluation, and placement when a referral is made

·         Determine makeup of multidisciplinary committee to evaluate and place the student if eligible.  The parents should be invited to participate as members of the committee. 


(5)    Placement

·         Assure that evaluation of the data and placement are done by persons knowledgeable about the student, the data, and placement options.

·         Assure that decision about placement are based upon the child’s individual needs and the least restrictive environment considerations.







(6)    Section 504 Due Process Procedures

·         The hearing procedures for complaints involving identification, evaluation and/or placement of students under Section 504 of the Rehabilitation Act of 1973 as amended, are set forth in school policy/ regulation entitled Section 504 Due Process Procedures. 












































The following are some examples of how schools could discriminate against individuals with disabilities:

















Annual Notice and Forms for

Section 504/ADA Meetings










(Form A)



Each school must provide and/or post a form to individuals with disabilities regarding the school’s obligations under Section 504/ADA.







Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act prohibits discrimination against persons with a disability in any program receiving federal financial assistance. Section 504/ADA defines a person with a disability as anyone who


Has a mental or physical impairment that substantially limits one or more major life activities such as caring for one's self, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning, and working. General functions include: lifting, bending, sleeping, reading, concentrating, thinking, communicating, and eating.  Major bodily functions include: the immune system, digestion, bowel, bladder, respiratory, cell growth, neurological, brain, circulatory, endocrine, and reproductive functions. 


The school has the responsibility to provide adjustments, modifications, and necessary services to eligible individuals with disabilities.


The school acknowledges its responsibility under Section 504/ADA to avoid discrimination in policies and practices regarding its personnel and students. No discrimination against any person with a disability shall knowingly be permitted in any program or practice in the school.





(Form B)



Section 504 is an Act that prohibits discrimination against persons with a disability in

any program that receives federal financial assistance. The Act defines a person with a disability as anyone who:


Has a mental or physical impairment that substantially limits one or more major life activities such as caring for one's self, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning, and working. General functions include: lifting, bending, sleeping, reading, concentrating, thinking, communicating, and eating.  Major bodily functions include: the immune system, digestion, bowel, bladder, respiratory, cell growth, neurological, brain, circulatory, endocrine, and reproductive functions. 


In order to fulfill its obligations under Section 504/ADA, the school recognizes a

responsibility to avoid discrimination in policies and practices regarding its personnel

and students. No discrimination or harassment against any person with a disability will knowingly be permitted in any of the programs and practices in the school system.


The school has specific responsibilities under the Act, which include the responsibility to identify, evaluate and, if the student is determined to be eligible under Section 504/ADA, to afford access to appropriate educational services.


If the parent or guardian disagrees with the determination made by the professional

staff of the school, he/she has a right to a hearing with an impartial hearing officer.

The Family Educational Rights and Privacy Act (FERPA) also specifies rights related to educational records. This Act gives the parent or guardian the right to do the following:

§  Inspect and review his/her student’s educational records.

§  Make copies of these records.

§  Receive a list of all individuals having access to those records.

§  Ask for an explanation of any item in the records.

§  Ask for an amendment to any report on the grounds that it is inaccurate, misleading, or violates the student’s rights.

§  Request a hearing on the issue if the school refuses to make the amendment.


If there are questions, please feel free to contact:

Name: Steve Loyd, Superintendent or designee

Section 504/ADA Coordinator    

(307) 276-3322


(Form C)



If the school suspects a student has a disability, then parental notice is given and an

individual evaluation is conducted. The following are some considerations for meeting 504 evaluation requirements:









The school may refuse to conduct an evaluation, but it has the obligation to inform the parents of the reasons for the refusal and their right to file a grievance, contact the Office for Civil Rights or request a due process hearing. 




(Form D)





Please keep this explanation for future reference. 


Section 504 of the Rehabilitation Act of 1973

Title II of the Americans with Disabilities Act of 1990


The following is a description of the rights granted by federal law to students with handicaps as defined by Section 504 of the Rehabilitation Act of 1973 as amended.  The intent of the law is to keep you fully informed concerning decisions about your child and to inform you of your rights if you disagree with any decisions. 


District staff will be trained regarding the rights granted by federal law to students with handicaps and will be required to evaluate and place students to protect those students’ rights, including the rights as defined by Section 504 of the Rehabilitation Act of 1973 and Title II of the Americans with Disabilities Act of 1990, specifically including, but not limited to, those set forth below.


You have the following rights: 











You have the right to request an evaluation under Section 504 regardless of whether an IDEA evaluation has been requested or initiated. 











The person in this district who is responsible for assuring that the district complies with Section 504 of the Rehabilitation Act of 1973 is: 


         Section 504 Coordinator

         Sublette County School District No. 9

         Steve Loyd, Superintendent or designee

         PO Box 769/115 South Nichols St., Big Piney, WY  83113

         (307) 276-3322










The school is requesting your consent to conduct the following evaluation procedure:


Evaluation Procedures:                        Person Responsible:

_______________________________ ________________________________

_______________________________ ________________________________

_______________________________ ________________________________

_______________________________ ________________________________


I give written consent to have my student evaluated for possible Section 504 eligibility and received a copy of my parental rights. 


_________________________             _______________________

Parent Signature                                     Date























(Form E)




Student: ______________________________Date:____________________________

School: _______________________________Date of Birth: _____________________

Teacher: ______________________________Grade: ___________________________

Parent: _______________________________Phone: ___________________________

Address: _______________________________________________________________

Referred by: ____________________________________________________________

Position: _______________________________________________________________


1. Reason for referral: ____________________________________________________






2. Accommodations and interventions attempted:










3. Has the student ever been referred, evaluated, and/or received services from special education? _____ YES ______ NO If yes, explain:______________________




4. Referral action:






_________________________________________          ___________________

Signature of Building Section 504 Representative         Date




(Form F)




Student: _____________________________________________ Date: ___________

School: ______________________________________________


Dear Parent or Guardian:


This letter is to inform you that we have some concerns about your student’s progress at school. We have attempted some interventions with your student. They include those listed below:







We would like to arrange a meeting to discuss eligibility for further accommodations/services in order to ensure that your student is afforded an appropriate education. Discussion will include whether or not your child may qualify for accommodations and services under Section 504 of the Rehabilitation Act.  An initial meeting to discuss these issues and to determine whether or not a more formal evaluation of your child and the procedures therefore should be conducted to determine his/her eligibility under Section 504 for further accommodations has been scheduled for: _________________________________________________________. 


We have scheduled a meeting on _________________________________. This meeting will be held at ______________________________to discuss your student’s educational needs. We would very much appreciate your participation.


If you have any questions, or if this meeting time is not convenient for you, please call me at ___________________________. We will discuss your questions or arrange a mutually convenient meeting time.




______________________________________  ____________________________

Name                                                                                               Position


Copies to 504 Team Members and Case Manager File







(Form G)




Student______________________________ Date___________________

School ______________________________ DOB___________________

Review Date __________________________ Case Manager__________


Part 1: Justification for services


[ ] YES [ ] NO


[ ] caring for one’s self                              [ ] hearing

[ ] performing manual tasks                         [ ] speaking

[ ] walking                                                    [ ] working

[ ] seeing                                                      [ ] learning

[ ] breathing                                                 [ ] lifting                      

[ ] bending                                                   [ ] sleeping

[ ] reading                                                    [ ] concentrating

[ ] thinking                                                   [ ] communicating

[ ] eating                                                      [ ] immune system

[ ] digestion                                                  [ ] bowel

[ ] bladder                                                    [ ] respiratory

[ ] cell growth                                               [ ] neurological

[ ] brain                                                        [ ] circulatory

[ ] endocrine                                                [ ] endocrine

[ ] reproductive functions


2. The impairment impacts the student’s educational program.

         [ ] YES [ ] NO


3.  Is the student eligible for Section 504 accommodations?

[ ] YES [ ] NO


4. Briefly document the basis for determining the disability.




5. Accommodations and Services (Steps to be taken by both staff and student)









6.  DURATION OF ACCOMMODATION(S) From __________ To __________



7.  Review/Reassessment Date:  ____________________________________________




504 Plan Participants

(Name and Title)

________________________________ __________________________________

________________________________ __________________________________

________________________________ __________________________________

________________________________ __________________________________

________________________________ __________________________________

________________________________ __________________________________

________________________________ __________________________________


I agree to the above plan and give permission for my child to receive the above mentioned services.  I received a copy of my parental rights.  I understand that if I disagree with the content of this plan, I have the right to ask for a Section 504 review meeting or impartial hearing by filing a written request with the District Section 504 Coordinator. 


_______________________________   ____________________________

Parent                                                          Date


Original to Office of Special Services

Copies to: Parent/Guardian/Adult Student

           Case Manager File





(Form H)



Student_______________________________________ Date__________________


Case Manager_________________________________


Purpose of meeting: It is necessary to periodically review the student's progress under Section 504 services and make recommendations to continue, modify, or terminate the program(s). (The 504 plan should be reviewed once each year.)


Discussion of progress____________________________________________________






[ ] Continue present services with no changes.

[ ] Modify the present program (see attached).

[ ] Conduct additional evaluations.

[ ] Exit from program based on the following evaluation results.


Discussion of recommendations____________________________________________





The following members of the Section 504 Committee agree with the recommendations:




____________________________            ____________________________

Parent                                                         Counselor


____________________________            ____________________________

Classroom Teacher                                   Nurse 


____________________________            ____________________________

School Principal                                        Other


Exit Date: ______________________



Section 504/ADA Checklist

Name:  ____________________

Date:  _____________________


Initial Referral

¨   Information for Parents Regarding Section 504 (Form A)

¨   Section 504 Referral (Form B)

¨   Notice to Parents (Form C)

¨   Section 504 Parent Rights (Form D) w/Consent Signed

¨   Section 504 Evaluation Procedures (Form E)


Eligibility and Initial Services

¨   Notice to Parents (Form C)

¨   Section 504 Student Accommodation Plan (Form F)

¨   Section 504 Parent Rights (Form D) – Consent not needed

¨   School Individualized Health Care Plan (Form G) - Optional

¨   Emergency Health Care Plan (Form H) – Optional


Annual Review

¨   Notice to Parents (Form C)

¨   Section 504 Review of Services (Form I)

¨   Section 504 Parent Rights (Form D) – Consent not needed

¨   Section 504 Student Accommodation Plan (Form F) – If revised

Please send original copies of the 504 plan with the checklist to ________________ – District 504 Coordinator at __________________ school within one (1) week of the meeting.


(Form I – Optional)



Student_________________________________ Effective Date_____________

Parent__________________________________ School___________________

Physician________________________________ Nurse____________________


_____Special Education _____Section 504 _____General Education


1. Brief Description of Condition:






2. Concerns:






3. Goal:






4. Intervention and Procedures:






5. Necessary Staff Training:






I have read and approve of the above health care plan for:

____________________________________________        Date:______________

___________________      _____________________  __________________

Parent                                 Child’s Physician              Nurse who provides

services in the school  -29-

(Form J – Optional)


Date: ______________


School: __________________________ Birth date: ______________ Grade: ______________

Preferred Hospital in Case of Emergency ____________________   Phone:_______________

Parent/Guardian:_____________________________  Phone:(h)________________________


Physician: __________________________________ Phone:__________________________

Medical Condition:_____________________________________________________________


Treatment Program: ______________________________________________________________________________


Signs of Emergency:____________________________________________________________


Actions to take during emergency:




If an emergency occurs and is life-threatening, immediately call 911and/or a designated emergency number.

a. State who you are    b. State where you are.         c. State problem

d. Stay with student or designate another adult to do so.

e. Call or designate someone to call the hospital.


The following staff members are trained to deal with an emergency and to initiate the appropriate


___________________________                  ______________________________

___________________________                  ______________________________

I approve the above Emergency Care Plan and request school personnel to follow the above plan in the event of an emergency involving my child. I will notify the school immediately if my child’s health status changes or if there is a change or cancellation of this Emergency Care Plan.


In consideration of this authorization made at our request, the undersigned agrees to indemnify, defend, and save harmless the School Board, the individual members thereof and any officials or employees involved in the rendering of care in accord with the above Emergency Care Plan from any claims or liability for injury or damages, including but not limited to costs and reasonable attorney’s fees, caused or claimed to be caused or to result from the administration of care in accord with the above Emergency Care Plan.



Address: ______________________________________________________________________


(Form K)




An individual or an organization may file a complaint with the regional Office for Civil Rights (OCR). An OCR complaint must be filed, in writing, within 180 days after the violation has occurred. In certain cases, OCR will consider complaints where more than 180 days have elapsed.


Anyone wishing to file a formal complaint with OCR should submit in writing the

following information in a letter or on the Discrimination Complaint Form available

from OCR regional offices and send to:  U.S. Department of Education, Office of Civil Rights, Region VIII, 1244 Speer Boulevard, Suite 310, Denver, Colorado 80204-3582,






A school may not retaliate against any person who has made a complaint, testified, assisted, or participated in any manner in an investigation.


Adopted:  9/19/17