What does a 504 Plan look like?

Here is a sample 504 Plan. 

SCHOOL NAME Accommodation Plan Section 504 of the Rehabilitation Act of 1973 Student:                                               School Year:   2019-2020 Conference Date:  Grade:  Teacher:  Parents:   Address: Phone:    Is there a documented physical or mental impairment, which substantially limits a major life activity?               Yes            No       Is this student qualified under IDEA?             Yes            No       Does this student require accommodations designed to meet his/her needs as adequately as the needs of non-handicapped students?     Yes            No       Nature of Disability: Data Sources Used for making 504 decision: Check the major life activities that are substantially limited by the physical or mental impairment:  Caring for oneself                           Speaking  Performing manual tasks                Breathing                                        Hearing                                           Learning  Eating                                             Reading  Sleeping                                          Concentrating  Walking                                          Thinking  Lifting                                            Communicating  Bending                                          Working  Other                                                              None                                                             Description of how disability affects major life activity: People responsible for accommodations: Describe the appropriate placement: How will the accommodations address the effects of the physical or mental impairment? Accommodations for the Student: Review/Reassessment Date:  Participants Names                                         Title: Parent Signature_____________________________________Date________________

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