Section 504 Process Tool Kit




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Section 504 Process Tool Kit






Section 504 Process Tool Kit
Tool #1: Section 504 Procedural Guideline Sheet
Tool #2: Section 504 Process Referral
Tool #3: Section 504 Parent’s/Student’s Rights

Tool #4: Section 504 Information Sheet

Tool #5: Notice and Consent for Initial Evaluation for Section 504

Tool #6: Parent Invite to Section 504 Eligibility Meeting & Prior Written Notice


Tool #7: Section 504 Process Eligibility Form
Tool #8: Supplemental Medical Impairment Form
Tool #9: Supplemental Behavioral/Emotional Impairment Form
Tool #10: Supplemental Academic Impairment Form
Tool #11: Proficiency Test Declaration
Tool #12: Section 504 Accommodation Plan
Tool #13: Section 504 Grievance Procedure
Tool #14: Section 504 Grievance Forms
*Formal Written Statement of the Grievance

*Written Reply to Grievance

*Superintendent’s Written Response

Procedural Guideline Sheet

When a student is suspected to have a medical, emotional, or academic impairment which may substantially limit a major life activity, that affects learning, then the following steps should be followed:

Step 1. The Building Principal and Classroom Teacher will provide the parent(s) with the Section 504 Parent’s/Student’s Rights Form and the Section 504 Information Sheet. Additionally, the parents will be asked to sign the Notice and Consent for Initial Evaluation for Section 504 Accommodations.

Step 2. The Building Principal and Classroom Teacher will complete a Section 504 Process Referral and send it, along with the signed Notice and Consent for Initial Evaluation for Section 504 Accommodations, to the Office of Pupil Personnel.

Step 3. The Building Principal will begin the evaluation process, and information collecting process. The teacher may be asked to complete the Section 504 Accommodation Checklist.

Step 4. The Building Principal will schedule a Section 504 Eligibility Meeting. The parents, Classroom Teacher, Building Principal, and a representative from the Pupil Personnel Office should be invited to this meeting. Written notice of the meeting should be provided to the parents using the Parent Invitation to Section 504 Eligibility Meeting.

Step 5. The Section 504 Eligibility Meeting:

The meeting should include: Parents, Classroom Teacher, Building Principal, and a representative from the Pupil Personnel Office. Additional personnel can be in attendance as needed.



The team will review evidence that a medical, emotional, or academic impairment exists and whether this impairment substantially limits one or more major life activities which negatively impacts learning. The team will use the Section 504 Process Eligibility Form, and either the supplemental Medical Impairment Form, Behavioral Impairment Form, or Academic Impairment Form.

Step 6. If the team determines that there is evidence that an impairment exists and it limits one or more major life activities which negatively impacts learning then a Section 504 Accommodation Plan and a Testing Declaration will be completed. Copies of these documents should be provided to all team members and additionally, a copy should be placed in the student’s cumulative folder. One copy of the Testing Declaration must be sent to the Pupil Personnel Office.

Step 7. The Section 504 Assistance Plan (developed above) should be reviewed each academic year. Determination of continued need and plan changes should be made by a team that includes the parent.

Step 8. If the team determines that there is not evidence that an impairment exists and/or it does not limits one or more major life activities which negatively impacts learning then future steps will be discussed. These steps could include development of an intervention plan.

Step 9. If the parents disagree with the results of the eligibility meeting than the grievance procedure begins (see attached information).


504 Referral

Child’s Name:      

Student ID:      

Grade:      

Date of Meeting:      

DOB:     

Home School:     




Mother’s Name:     

Father’s Name:     

Home Phone:     

Home Phone:     

Cell Phone:     

Cell Phone:     

Home Address:     

Home Address     

Reason for Referral:  Medical Behavior/Emotional Academic

Explain Reason for Referral:     

Educational History/Attendance:     

Number of School Districts Attended: ____________ Years at present school:_____________

Attendance: Regular Irregular (days absent     , days tardy     )

Is the student age-appropriate for grade level? Yes No

Retained (specify grade)

Started school late

Held out of school by parent

unknown
***Attach a copy of the student’s most recent test results and any previous results (e.g. DIBELS, DRA, Ohio Diagnostic Test, SAT9, Explore, OAA, OGT). Also attach attendance records, discipline referral, or other school documentation as necessary



***Summary of Test Scores:

Grade K

Test:

Results:

Grade 1

Test:

Results:

Grade 2

Test:

Results:

Grade 3

Test:

Results:

Grade 4

Test:

Results:

Grade 5

Test:

Results:

Grade 6

Test:

Results:

Grade 7

Test:

Results:

Grade 8

Test:

Results:

Grade 9

Test:

Results:

Grade 10

Test:

Results:

Grade 11

Test:

Results:

Grade 12

Test:

Results:



Current Classroom Grades:

Subject

Grade

Teacher/Comments


































































Medical & Physical History (Answer questions if you have any information)

1. Are you aware of any relevant medical history or concerns related to this child? Yes No

If yes, please explain     



2. Does this child take any medication? Yes No

If yes, what medication and for what condition?     



3. Check each that applies related to vision and hearing

Vision: Pass Fail (date of screening:     ) Hearing: Pass Fail (date of screening:     )

 Appears within normal limits  Appears within normal limits

 Wears glasses or contact lenses  Wears a hearing aid or uses a hearing device

 Vision may need to be tested  Hearing may need to be tested


Learning and Work Profile

1. How quickly does this child learn new material (i.e. pick up novel concepts)?

very slowly slowly average quickly very quickly

2. How consistent is the quality of this child’s academic work?

consistently poor often poor variable often successful always successful

3. How frequently does the child take more time to complete work than his/her classmates?

never rarely sometimes often very often

4. How frequently does this child require assistance to accurately complete his/her work?

never rarely sometimes  often very often

5. How frequently does this child have difficulty recalling material from the previous day’s lesson?

never rarely sometimes often very often





Work Completion

6. In general, estimate the percentage of class work independently & accurately completed relative to classmates.

0-49% 50-69% 70-79% 80-89% 90-100%

7. Estimate the percentage of homework accurately completed relative to classmates.

0-49% 50-69% 70-79% 80-89% 90-100%

8. In general, what percentage of the time does the student need assistance from you or another adult in the room to complete work?

0-49% 50-69% 70-79% 80-89% 90-100%

9. In general, rate the student’s effort/motivation relative to classmates

much worse somewhat worse about the same somewhat better much better

10.How does the student perform compared with peers in the following areas (if applicable)

Self Help Skills (Adaptive Behavior)

much worse somewhat worse about the same somewhat better much better



Test Taking Skills

much worse somewhat worse about the same somewhat better much better



Study Skills

much worse somewhat worse about the same somewhat better much better



Organizational Skills

much worse somewhat worse about the same somewhat better much better



Behavioral Concern Checklist

Off-Task Passive (Short Attention Span)

Physical Aggression Towards Adults

Impulsive Acting Out

Physical Aggression Towards Peers

Invading Other’s Physical Space

Stealing

Withdrawn Behavior

Poor Work Independence / Work Avoidance

Poor Peer Relationships

Poor Work Completion

Poor Adult Relationships

Destruction of Property

Making Noises During Class

Constant Complaining

Calling out During Class

Lying

Talking with Peers During Class

Excessive Questions During Class

Disrespectful/Inappropriate Language

Arguing

Out of Seat

Temper Tantrums

Noncompliance with Requests

Hiding in the Classroom

Crying

Running Away from Adults

Poor Personal Hygiene

Negative Self-Statements

Playing with Objects During Instruction

Careless Work Completion

Teasing Peers

Threatening Others

Organization

Other (Explain)     

List the Student’s Strengths, Hobbies, and Interests

     



Current and Past Interventions

Child’s Name:      

Student ID:      

Grade:      

Date of Meeting:      

DOB:      






Intervention Name:     

Start Date:

Person(s) Responsible: Teacher Parent Student Other:     

Time: # of Days Each Week:      Number of Minutes Each Time:      

Location: In Classroom Outside of Classroom (where?):      

Delivery: 1:1 Small Group (# of students?):      

Special Materials:      

Brief Description:      

** See Attached Tier 2 Form See Attached Tier 3 Form



Intervention Name:     

Start Date:


Person(s) Responsible: Teacher Parent Student Other:     

Time: # of Days Each Week:      Number of Minutes Each Time:      

Location: In Classroom Outside of Classroom (where?):      

Delivery: 1:1 Small Group (# of students?):      

Special Materials:      

Brief Description:      

** See Attached Tier 2 Form See Attached Tier 3 Form




Intervention Name:     

Start Date:


Person(s) Responsible: Teacher Parent Student Other:     

Time: # of Days Each Week:      Number of Minutes Each Time:      

Location: In Classroom Outside of Classroom (where?):      

Delivery: 1:1 Small Group (# of students?):      

Special Materials:      

Brief Description:      

** See Attached Tier 2 Form See Attached Tier 3 Form




List additional current or past interventions - attached

Current and Past Modifications & Accommodations

Child’s Name:      

Student ID:      

Grade:      

Date of Meeting:      

DOB:      

Home School      


Modification= Alterations in classroom expectations or work requirements designed to help the student have access to the classroom and be a more successful member of the classroom.

Accommodation= Alterations in physical environment, classroom procedure, or materials characteristics (e.g., font of worksheets) designed to help the student have access to the classroom and be a more successful member of the classroom.

Check each major area below where accommodations for this student within the classroom have been made.

 testing materials

 grading practices

 assignments and materials

 instructional practices (i.e., presentation of subject matter)

 classroom arrangement or classroom environment

 classroom behavior management system

 instructional pace

 organization strategies

 medical need




Parental Involvement

Date(s) parent(s) was contacted regarding the concern(s)

     
How has the parent been involved in addressing the current concern?:

     





________________________________________________ ____________________

Person Completing the Referral Date
________________________________________________ ____________________
Principal’s Signature Date

Note: A complete 504 Referral includes this 504 Process Referral Form and a signed copy of the Notice and Consent for Initial Evaluation for Section 504 Accommodations.

Parent/Student Rights

Child’s Name:      

Student ID:      

Grade:      




DOB:     




Section 504 of the Rehabilitation Act of 1973 prohibits the discrimination against handicapped persons, including both students and staff members, by school districts receiving federal financial assistance.

An eligible student under Section 504 is a student who [a] has, [b] has a record of having, or [c] is regarded as having, a physical or mental impairment which substantially limits a major life activity such as learning, self-care, walking, seeing, hearing, speaking, breathing, working, and performing manual tasks.

Parents/guardians and students should be provided a copy of their rights prior to evaluation, when eligibility is determined, when a plan is developed, and before any significant change in the service plan.

Parents’/Student’s rights under Section 504 include the following:

1. You have a right to be informed by the school district of your rights under Section 504 (The purpose of this is to advise you of those rights.)

2. Right to receive all information in the parent’s or guardian’s native language or primary other mode of communication.

3. Right to have your child receive a free appropriate public education. This includes the right to be educated with non-handicapped students to the maximum extent appropriate. It also includes the right to have the school district make reasonable accommodations to allow your child an equal opportunity to participate in school and school-related activities.

4. Right to have educational evaluation and placement decisions made based on information from a variety of sources and by persons who know the needs of the student. This evaluation should take place prior to initial 504 placement and before any subsequent significant change in placement.

5. Right to receive notice a reasonable time before a district identifies, evaluates, or changes your child’s placement.

6. Right to inspect and review all your child’s educational records, including the right to obtain copies of education records at reasonable cost unless the cost would deny you access to the records, and the right to amend the record if you believe information contained in the record is inaccurate or misleading. If school district refuses to amend the record, you have a right to request a hearing.

7. Right to periodic re-evaluations and an evaluation before any significant change in program or modification in service.

8. Right to request mediation hearing related to decisions or actions regarding your child’s identification, evaluation, educational program or placement. A copy of the district’s grievance procedures can be obtained from the building principal. You and the student may take part in the hearing and have an attorney represent you. Parents have the right to request a hearing before an impartial hearing officer by notifying the district ADA/§504 Coordinator:

Laura Nazzarine, Director of Special Education – West Clermont Schools

4350 Aicholtz Rd. Suite 220, Cincinnati, Ohio 45245

9. Right to appeal the impartial hearing officer’s decision.

504 Information Sheet

Child’s Name:      

Student ID:      

Grade:      




DOB:     





What is a “504”?

Section 504 of the Rehabilitation Act of 1973, as amended by the ADA Amendments Act of 2008 (herinafter “Section 504”), is Congress’ directive to schools receiving any Federal funding to eliminate discrimination based on disability from all aspects of their school operations. It states: “No otherwise qualified individual with a disability shall solely by reason of his/her 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.” Since the School District is a recipient of Federal dollars, its administrators and staff are required to provide eligible disabled students with equal access (both physical and academic) to services, programs, and activities offered by its schools. Section 504 is a civil rights statute and not a special education statute.



Who is eligible for a 504?

By definition, those eligible for 504 include “any individual who has a physical or mental impairment which substantially limits one of more major life activities (e.g., learning) and who has a record of such an impairment.” Students who were once in special education but are now not receiving those services are also eligible if the need exists.



How does a student become eligible for a 504?

A staff member or a parent can make a referral for 504 consideration. The referral is processed through the building intervention team. Data collection may include a record review, vision/hearing screening, work samples, teacher/parent input, and possibly academic screening. The intervention team will determine eligibility based on educational data. The decision is documented using standardized district forms.


What happens if the student is eligible?

If the team determines that the student is eligible for 504, a 504 plan is developed. This plan documents accommodations that can be made in the regular education classroom. It is signed by the team members and is filed in the student’s cum folder. The plan is then implemented. The implementation is required and the plan is a legal document. The plan is reviewed and updated annually. Proficiency test accommodations can be recommended but the student cannot be exempted based on a 504 Accommodation Plan.



If I have questions, whom do I ask?

If you have any questions or need additional information, please address your questions to the Building Principal named below:



Building Principal:

     

Telephone Number:

     


Manifestation Determination Worksheet

Student: D.O.B.: ID: Date: School:

A. Sources of Information (Check all that apply)

 Assessment / evaluations (attach assessments and summaries)

 Medical Information, Including diagnostic and medication (attach results)

 Interviews conducted (attach summaries)

 Direct Observations (attach summaries)

 Discipline reports for the current school year (attach)

 Functional Behavioral Assessment/Behavior Intervention Plan (attach)

B. Does the student have a history of disciplinary actions?

1. Number of incidents:_________ dates:____/____/____, ____/____/____,

____/____/____, ____/____/____, ____/____/____, ____/____/____.

2. Number of administrative assignments of out of school suspensions:______, total

Number of actual days:______.

3. Longest number of consecutive days suspended: ______ days.



C. What is the history of behavioral interventions?

1. Does the student have a behavior support plan based on a functional behavioral

assessment?  Yes  No If no, explain:
2. Have any interventions tried in the past been effective?

3. Have the interventions and plan been reviewed when they are not effective?


4. Has there been a change in behavior patterns over time (increase in frequency or

intensity)?  Yes No Explain


D. Nature of the behavior subject to disciplinary action:

E. Does the proposed disciplinary action constitute a change in placement (more than 10

consecutive days or a series of short term suspensions which constitutes a change in

placement)?

 NO. Proceed with disciplinary action

 YES. Consider the following factory in making a manifestation determination:

1. What is the student’s disability, including it’s behavioral characteristics and specific

severity?

2. To what extent does the student’s disability prevent him/her from understanding the

impact and consequences of his/her actions?

3. Does the disability impair the student’s ability to control the behavior at issue and to

what extent?  Yes  No Explain:

4. Has this behavior or similar behaviors associated with the disability been exhibited in

the past? Yes No Explain:

5. What information from evaluations and additional diagnostic procedures, including

information provided by the parents, is being considered?

6. What information is available from persons who observed the misbehavior when it

occurred?

7. What is the context in which the behavior occurred? Including the antecedent

behaviors and circumstances?

8. Is the student’s IEP appropriate?  Yes  No If No, Explain:


9. Is placement appropriate?
10. Is the student’s IEP being implemented and does it include the necessary special

education and related services, including the use of supplementary aids and services,

strategies and interventions, and behavior management techniques?  Yes No

Explain:
11. Were behavior intervention strategies provided, consistent with the student’s IEP and

placement? Yes No Explain:

12. Was the student told about and explained the consequences of the school policy

Regarding the behavior in question? Yes No Explain:
Based on the above factors, is the behavior a manifestation (or related to) of the child’s disability?

 NO. The student may be disciplined using procedures applicable to non-disabled students

(except that under IDEIA, educational services may not cease). Parents shall be informed

of their procedural safeguards. A new functional behavior assessment must be completed and a behavioral support plan will be developed.

 YES. Reevaluate the student’s IEP for appropriateness, including the current placement.

A new functional behavioral assessment and behavioral support plan should be



completed or existing one(s) revised. The student may not be removed.


Name

Title

Date

Agree

Disagree*

Signature


































































































































Notice and Consent for Initial Evaluation for Section 504 Accommodations


  • Please attach a statement clarifying reason for disagreeing with the team.

Child’s Name:      

Student ID:      

Grade:      

Date:      

DOB:     

Home School:     

Your child is having difficulty in certain areas of his/her school performance. The Intervention Team plans to begin a screening process so that we may be able to offer suggestions as to how he/she can best be served in our school.

This letter is to request your consent to continue the problem-solving process and gather information to determine your child’s educational needs and whether she/he is eligible for assistance in the regular education classroom under Section 504. You are an essential member of the Section 504 Team and may fully participate in this problem-solving process. We are requesting your consent for these reasons:

     







A Section 504 Evaluation Review and Eligibility Determination meeting will be scheduled upon receipt of your consent and you will be invited to this meeting.

If your child is determined to be eligible under Section 504, the committee, with your assistance, will develop a 504 accommodation Plan to address your child’s educational needs.

For further information, we have included a description of the rights you and your child are entitled to under Section 504 of the Rehabilitation Act of 1973.

If you have any questions or need additional information, please address your questions to the Building Principal named below:



Building Principal:




Telephone Number:




If you consent to the evaluation, check the appropriate box, sign, and return one copy of this letter. Keep the Section 504 Parent’s/Student’s Rights and the Section 504 Information Sheet for future reference.



As the parent/legal guardian of the above referenced student, I consent to an evaluation under Section 504.



As the parent/legal guardian of the above referenced student, I do not consent to an evaluation under Section 504.

Date




Parent/Guardian Signature

Parent received a copy of their rights under Section 504:  Yes  No Parent Initials:_______

Parent Invitation to Section 504 Eligibility Meeting

Child’s Name:      

Student ID:      

Grade:      

Date of Meeting:      

DOB:     

Disability:     

Date:     


Dear Parent:     

Child’s Name:     

Your child’s Section 504 evaluation has been completed. We would like to invite you to a meeting to discuss the results of this evaluation and to determine whether your child is eligible for services under Section 504 of the Rehabilitative Act of 1973.






A meeting to discuss evaluation and eligibility has been set for:

     

on


     

at

     

Time




Date




Location

The following people will be in attendance:

     




     

Name & Title




Name & Title

     




     

Name & Title




Name & Title

     




     

Name & Title




Name & Title

We encourage you to attend and participate. The information you can provide about your child is important. You may bring other people who you think can assist in this important meeting regarding your child.

Please complete and return the attached response form within five (5) days. In the event that school is closed due to inclement weather, on the day of the scheduled meeting, the meeting will not be held and someone will contact you to reschedule.

If you have any questions or need additional information, please contact:

Name & Title     




Telephone Number     

*Please complete the attached Parent Invitation Response Form and return it to your child’s school.

504 Parent Invitation Response Form

Child’s Name:      

Student ID:      

Grade:      

Date of Meeting:      

DOB:     

Disability:     

Please return this form to the person listed at the bottom of the page within five (5) days.

Name of Child:      ____________________________________________________

(Check all that apply below)










Date




Time
 I will attend the meeting at the scheduled time.

 I want to come, but I cannot attend the meeting at the scheduled time.


Please contact me at ___________________ to make other arrangements.
I am available ___________________________ ________________________

Date(s) Time(s)

 I will need an interpreter (Please specify): _____________________________________________
 I have other special needs (e.g., accessibility, transportation - please specify):
___________________________________________________________________________

 I cannot attend.

 I will be bringing guests. (It is not required that you bring guests, but you may bring other people to the meeting.) Their names are
________________________________________________________________

Name
________________________________________________________________

Name











Parent/Guardian Signature




Date

Please return this form to:



     

Name & Title

     

School Phone#

     

Address





Prior Written Notice to Parents

504 Plans
Date: ___________ Student: ________________________________________ Date of Birth: ___________

This is to notify you of the District’s action regarding __________________________________’s educational program.




  1. Description of the action:

 Refusal to Consent to 504 Evaluation

 Initial 504 Evaluation

 Development of 504 Plan

 504 Review

 504 Reevaluation

 Change of 504 Services

 504 Issues/meetings where the parent(s)/guardian(s) disagree with the District

 Other (describe action taken): ____________________________________________________________



_____________________________________________________________________________________


  1. An explanation of why the School District is taking the action described above: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

  2. A description of any other options the School District considered and the reasons/data why those options were rejected: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

  3. A description of each evaluation procedure, test, record, or report the School District used as a basis for the proposed or refused action: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

  4. Other factors that are relevant: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

  5. Provision of procedural safeguards:

As a parent of a child with a suspected or identified disability, you have procedural safeguard protections. Please contact me if you have any questions about the action(s) described above, your rights, as described in the Notice of Section 504/ADA Procedural Information and Rights, or other related concerns please contact:
Name: __________________________________________ Title: __________________________________
Address: _________________________________________ School District: __________________________
City, State, Zip: ____________________________________
Telephone: _______________________________________ Email: _________________________________
504 Process Eligibility Form

Child’s Name:      

Student ID:      

Grade:      

Date of Meeting:      

DOB:     

Home School:     

Evidence that a student has a disability that substantially limits learning or adversely affects the students educational performance



Medical


(see attached Supplemental Medical Form)



Behavioral/Emotional

(see attached Supplemental Behavioral/Emotional Form)




Academic

(see attached Supplemental Academic Form)


Cultural, Economic, and Environmental Factors: The student’s limited academic and/or behavioral performance is not caused by cultural, economic, or environmental circumstances.

YES

NO

Medication: The student currently takes medication.

YES

NO

If YES Please indicate medication name, dosage, and when administered.
Documentation of Physical or Mental Impairment

 See attached information from health care professional

 See attached information from recent Multi-factored Evaluation or Re-evaluation

 No official documentation is available



Describe the Limiting Effects on Learning

     
















 See attached Intervention Documents  See attached test scores  See attached school records See attached Observation

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