SECTION THREE: Section 504 Resources Sample Forms xample

Section 504 Manual 1

SECTION THREE: Section 504 Resources

Sample Forms

xample and sample forms included in this document are intended to be

guidance. School districts/charter schools are not required to use the

exact format. School districts/charter schools are responsible for

ensuring the accessibility of their documents for their end-users. As

appropriate, make available necessary documents in multiple languages

and alternative formats. The use of district or school letterhead on Section 504 forms

are encouraged.

Available Sample Documents

Notice of Nondiscrimination

Referral

• Section 504 Referral for Evaluation ^

• Section 504 Parent Notice of Referral and Consent to Evaluate

Data Collection

• Consent to Release Information (Third Party)

• Section 504 Student Input

• Section 504 Parent Input

• Section 504 Teacher Input

Evaluation and Review

• Section 504 Notice of Meeting

• Section 504 Team Evaluation and Determination

• Section 504 Plan

• Section 504 Receipt of Plan Acknowledgment

• Section 504 Plan Review Teacher Input

• Section 504 Plan Review

• Section 504 Manifestation Determination Review

• Section 504 Process Checklist

Parent Rights and Grievance Process

• Section 504 Notice of Parent and Student Rights *^

• Section 504 Grievance Procedures *^

• Section 504 Complaint and Grievance Filing ^

• Section 504 Complaint and Grievance Record

• Impartial Hearing Procedure

• Impartial Hearing Agenda

• Impartial Hearing Review Procedure

* These documents should be presented and offered at every Section 504 meeting.

Section 504 Manual 2

^ These documents should be readily available on the district/charter website.

Sample Notification of Nondiscrimination

An effective notice of nondiscrimination makes it clear that the institution does not

discriminate on the basis of disability, has a duty to locate students with disabilities, and

how to contact the Section 504 Coordinator.

It is not sufficient to place the Notification of Nondiscrimination on a website without

publishing it elsewhere. The notice of nondiscrimination may be included in the

following:

• Student handbooks

• Website

• Catalogs and Course Listings

• Parent/Student Bulletins/Newsletter

• Brochures

• Enrollment and employment

application

• Recruitment materials

When the service area includes a significant community of individuals whose primary

language is not English, the notification of nondiscrimination should be published in the

language spoken by that community.

The notice may include additional persons designated to coordinate other civil rights

activities and their contact information. For assistance on a combined civil rights

nondiscrimination notice see SECTION THREE: Links (e.g., Public Resources).

Notification of Nondiscrimination

The ______________________________ School District does not discriminate on the

basis of disability in admission or access to its educational programs, in treatment and

the administration of services it offers, in its recruitment, hiring and employment

practices, or in any aspect of its operations in violation of Section 504.

The ______________________________ School District takes appropriate steps to

notify students with disabilities and their parents or guardians of our duty to annually

identify and locate every qualified student with a disability residing in the school district’s

jurisdiction who is not receiving a public education.

___________________ is designated to coordinate Section 504 compliance activities at

_____________________ School District and may be contacted at:

[Name of Designated Individual and Position]

[Name of District/Charter School]

[Mailing Address]

[City, State, Zip]

[Telephone number]

This announcement is available in alternative formats to accommodate the hearing and

vision impaired. Information as to the existence and location of services, activities, and

Section 504 Manual 3

facilities that are accessible to and useable by individuals with disabilities may be

requested from the above-referenced coordinator.

Section 504 Manual 4

Sample Referral for Evaluation

Section 504 Referral for Evaluation

The ______________________________ School District has a duty to identify, locate,

refer and evaluate all students within this jurisdiction that may qualify for services under

Section 504 of the Rehabilitation Act of 1973.

• Anyone who believes that they have a child or know of a child that may have a mental or

physical impairment that substantially limits one or more life activities should complete

this form

(unless already identified under Section 504 or the Individuals with Disabilities

Education Act)

• Submit this form to [Name of 504 Coordinator]. They may be contacted at [phone number]

[email].

Today’s Date ______________________ School __________________________

Student Name __________________________________________________________

Date of Birth _______________ Age _________ Grade Level __________________

Referred By _______________________ Phone Number ___________________

Relationship to Student: ☐ Parent/Guardian ☐ District Employee ☐ Other: _________

Briefly indicate the observed disability or reason for referral:

______________________________________________________________________

_____________________________________________________________________

______________________________________________________________________

This is an effort by the _____________________________ School District to provide a

free appropriate public education and assure that every student has access to equitable

educational opportunities to be successful in our district and to fulfil their potential.

This portion completed by the Section 504 Coordinator

Student ID# ________________________

Date Referral Received _____________ Received by ________________________

Section 504 Manual 5

Sample Notice of Rights

Notice of Rights under Section 504

You have the right to be informed by the school system of rights granted under §504 found at Title 34, Part

104.32 of the Code of Federal Regulations (CFR).

EDUCATION

The student has the right to:

• Receive a free appropriate public education

designed to meet their educational needs as

adequately as the needs of non-disabled students

(34 CFR 104.33).

• Participate in and benefit from the district’s

educational programs without discrimination.

• Be provided an equal opportunity to participate in

the district’s nonacademic and extracurricular

activities.

• Be educated with students who do not have

disabilities to the maximum extent appropriate

(34

CFR 104.34).

• Be educated in facilities and receive services that

are comparable to those provided to students

without disabilities

(34 CFR 104.34).

• Receive accommodations, modifications, related

aids/services, and opportunities to participate in

school activities without cost, except for those fees

imposed on the parents of children without

disabilities. Insurance companies are not relieved

of any obligation to pay for services

(34 CFR 104.33).

• Receive special education services if needed.

EDUCATIONAL RECORDS

The parent has the right to:

• Review and receive copies of the student’s

educational records

(34 CFR 104.36), programs, and

activities in their native language.

• A response to requests for explanations and

interpretations of their student’s education records.

• Request a change to their student’s education

records if believed they are wrong, misleading, or

are otherwise in violation of privacy rights. If

request denied, the right to challenge the refusal

by requesting an impartial hearing.

SECTION 504 PROCESS

The student has the right to an evaluation before the

school determines if they are eligible under Section

504. The parent has the right to:

• Receive notice before the district takes actions

regarding the identification, evaluation, and

placement of their student

(34 CFR 104.36).

• Have evaluation and placement decisions made

by a group of persons who know the student, the

meaning of the evaluation information, and the

placement options available

(34 CFR 104.35).

• Have evaluation decisions based on a variety of

sources such as academic data, behavior data,

teacher and parent observations, physical

conditions, and medical records.

• Refuse consent for the initial evaluation of the

student.

If the student is eligible under Section 504, they have

the right to periodic reevaluations, including

reevaluations before any significant change is made

in their placement

(34 CFR 104.35).

IF THERE IS DISAGREEMENT WITH THE

DISTRICT’S DECISION

A parent that disagrees with the district’s decisions

regarding their student’s identification, evaluation,

educational program, or placement under Section

504, may submit a grievance or request an impartial

hearing

(34 CFR 104.36). A parent may take part in the

hearing and have an attorney as representation. A

parent may request a review of the hearing decision.

Clarification of these rights

and other concerns can be

made to the district’s Section 504 Coordinator:

[Section 504 Coordinator Name]

[Address]

[City, State, Zip]

[Phone Number], [E-mail]

A parent may file a complaint of discrimination with

the Arkansas Division of Elementary and Secondary

Education Equity Assistance Center (EAC), the U.S.

Department of Education

Office for Civil Rights (OCR)

or seek relief in federal court.

EAC

4 Capital Mall, Box 25

Little Rock, AR 72117

Phone: 501-682-4213

Fax: 501-682-7288

Email:

ADE.EquityAssistance

@ADE.Arkansas.gov

OCR Regional Office

One Petticoat Lane

1010 Walnut St., Suite

320 - 3

Floor

Kansas City, MO 64106

Phone: 816-268-0550

TTY: 800-877-8339

FAX: 816-268-0599

OCR.KansasCity@ed.gov

☐

I received a copy of the Notice of Rights under Section 504.

_________________________ _____________________

Parent or Guardian Signature Date

Section 504 Manual 6

Sample Parental Notice & Consent

Section 504 Parent/Guardian Notification of Referral & Consent for Evaluation

Date: ____________________

Dear _____________________:

[Student Name] has been referred for consideration for eligibility for services under

Section 504 of the Rehabilitation Act of 1973. Such services may result in your student

receiving additional assistance to aid them in their educational success. The Section 504 Team

will analyze a variety of sources to determine whether they have a qualifying disability. Your

student’s teacher(s), building administrator(s), counselor, and others may be involved in data

collection activities.

The district is requesting your consent to conduct an initial evaluation and based on it

provide necessary accommodations. The evaluation data collection may include a review of the

following as individually deemed appropriate:

Grades Teacher Observations Achievement Tests

Work Samples Parent Observations Screening Assessment

Attendance Medical Reports Other Tests

Behavioral Trends Psych-educational Evaluation Other Sources

You will be notified and invited to attend a Section 504 Team meeting to review

evaluation results and determine Section 504 eligibility. If eligibility is established, your student

may require Section 504 services. If so, the Section 504 Team will develop an accommodation

plan to provide educational opportunities equal to that of students without a disability.

Section 504 provides specific rights such as the required parental consent for evaluation.

These rights are summarized in the Notice of Rights under Section 504 document enclosed with

this notice. If you have any questions or concerns, contact [Section 504 Coordinator] at [Phone

Number] or [Email Address] or [Mailing Address] for assistance.

Sincerely,

Section 504 Coordinator, ____________________ ___________________

(Name) (Signature)

Parent/Guardian complete & return this form with any additional information (e.g., Parent Observations, Medical

Reports)

Concerning [student name] attending [school name],

☐ Yes, I give my written consent to have my student evaluated for Section 504 eligibility. I do

consent to the proposed evaluation

☐ No, I refuse and do not give my written consent to have my student evaluated for Section

504 eligibility. I do not consent to the proposed evaluation.

☐ I have received a copy of the Notice of Rights under Section 504

____________________________ ____________________________ __________

(Parent/Guardian Printed Name) (Parent/Guardian Signature) (Date)

____________________________________________________ _________________

(Address) (Phone)

This portion completed by the Section 504 Coordinator Date Received ___________

Copy provided to parent

☐

Section 504 Manual 7

Sample Parental Authorization for Release of Information

Parental Authorization for Release of Information

Student Name: _____________________________ Date of Birth: _____________________

School: ___________________________________

Information Requested (as appropriate)

☐

Psychological Evaluation

☐ Speech-Language Evaluation

☐ Vision Evaluation

☐ Hearing Exam Evaluation

☐ Occupational Therapy Evaluation

☐

Demographic and Social Histories

☐ Medical and Developmental Histories

☐ Medical Diagnosis

☐ Discharge Summary

☐ Physical Therapy Evaluation

☐ Other: ____________________________

____________________________________

Agency Name: _________________________________________________________

Agency Address: _______________________________________________________

Agency Phone: ________________________ Fax: __________________________

Agency Email: _________________________________________________________

I consent for the Agency listed above to release the information specified above to the

following:

School District/Charter: __________________________________________________

School District/Charter Address: ___________________________________________

District/Charter Phone: ______________________ Fax: ______________________

District/Charter Email: ___________________________________________________

I understand that I may revoke this consent in writing at any time and that my consent will

expire upon graduation or un-enrollment of the child listed above from the School/District.

_____________________________________ ________________________

Signature of Parent / Guardian Date

Any information received and maintained by the school district will be subject to the

Family Educational Rights and Privacy Act (FERPA).

Section 504 Manual 8

Sample Meeting Notice

Section 504 Meeting Notice

Student Name: _____________________________ Student ID#: _________________

School: ___________________________________ Grade: ______________________

[Date]

Dear [Parent or Guardian Name]:

You are invited to attend a meeting planned by the Section 504 Team to discuss

your child’s educational needs. Please notify the Section 504 Coordinator if you are not

available so that we may reschedule.

The meeting will be held on: [Meeting Date & Time]

The meeting will be held at: [Meeting Location]

The meeting is scheduled for the following reason(s)

☐ Initial Evaluation for Eligibility

☐ Section 504 Plan Review and Monitoring

☐ Reevaluation

☐ Manifestation Determination Reevaluation

☐ Other: ___________________________

While parents are not required participants of the Section 504 Team, you are

encouraged to attend and participate in the decision-making process. Your insights and

contributions will be helpful to the Section 504 Team in bringing about the most

appropriate decisions possible. If you have not already done so, complete and return

the Parent Input Form.

Section 504 provides specific rights to parents and students. These rights are

summarized in the Notice of Rights under Section 504 document enclosed with this

notice.

Contact [Section 504 Coordinator] at [Phone Number] or [Email Address] or

[Mailing Address] to confirm your attendance or if you have any questions\concerns,

require the use of an interpreter or would like to submit other requests for assistance.

Sincerely,

Section 504 Coordinator, ____________________ ___________________

(Name) (Signature)

Section 504 Manual 9

Sample Parent or Guardian Input Form

Section 504 Parent/Guardian Input Form

Student Name: _____________________________ Date of Birth: _________________

To assist the Section 504 Team in the evaluation of your child answer any question

below and submit this form to the Section 504 Coordinator, [Section 504 Coordinator

Name] at [Phone Number] by [Email Address] or [Mailing Address].

My Child’s Health (Check all that apply and/or explain responses as necessary.)

☐

My child has a physical or mental disability and a formal diagnosis.

☐ My child has a physical or mental disability and no formal diagnosis.

☐ My child had a serious physical or mental condition that has gone away.

Explain:

__________________________________________________________________________

☐ My child is receiving service(s) from another agency. Explain:

__________________________________________________________________________

__________________________________________________________________

________

☐ My child is not currently taking medications.

☐ My child is currently taking the following medications:

Name of medication:_______________________ Name of medication:_______________________

Purpose of medication:_____________________ Purpose of medication:_____________________

Dosage:_________________________________ Dosage:________________________________

Known side effects:________________________ Known side effects:________________________

My Child at Home (Check all that apply and/or explain responses as necessary.)

☐

My child usually eats breakfast.

My child goes to bed at the following time: _______________________________________

☐ My child needs or uses physical supports at home or in the community.

☐ My child gets along with siblings and people outside of school.

☐ There have been significant changes within the family

(e.g., divorce, separation, relocation,

serious illnesses, death, etc.).

☐ My child seems to have difficulty doing homework. On average, the amount of time spent

on homework each day is as follows:

_________________________________________

The following rewards and consequences are effective with my child -

Rewards:______________________________ Consequences:_____________________________

______________________________________ _________________________________________

Section 504 Manual 10

My Child at School (Check all that apply and/or explain responses as necessary.)

Some of my child’s strengths include:

__________________________________________________________________________

☐ My child is experiencing and/or mentioned difficulties in school. Explain:

__________________________________________________________________________

The cause of my child’s difficulties includes the following:

__________________________________________________________________________

My child’s success at school would be improved if the following was provided:

__________________________________________________________________________

Previously attend schools include:

__________________________________________________________________________

__________________________________ ______________________________

Parent or Guardian Signature Date

__________________________________ ______________________________

Parent or Guardian Signature Date

This portion completed by the Section 504 Coordinator Date Received ___________

Section 504 Manual 11

Sample Student Input Form

Section 504 Student Input Form

Student Name: ______________________________ Date of Birth: _______________

To assist the Section 504 Team in your evaluation, answer any question below and

submit this form to the Section 504 Coordinator, [Section 504 Coordinator Name] at

[Phone Number] by [Email Address] or [Mailing Address].

At School (Check all that apply and/or explain responses as necessary.)

☐

I struggle doing work by myself.

☐ I struggle doing work in groups.

☐ I struggle understanding directions at school.

☐ I find it hard to stay focused in class.

☐

All classes ☐ These classes: ___________________________________

☐ I get overwhelmed by all the:

☐

Sounds ☐ Sights ☐ Noises at school

☐ I find it hard to control my frustration or anger.

☐ I feel overwhelmed whenever I start a new project or assignment.

☐ It seems like my friends can take notes and record assignments better than I can.

☐ I can never finish my work in time, even when I know all the answers.

☐

I can never finish my tests or quizzes in time, even when I know all the answers.

At Home (Check all that apply and/or explain responses as necessary.)

☐ I struggle doing homework.

Amount of time I spend on homework each day: ____________________________

☐ I often forget what work was assigned in class.

☐ I often forget when assignments are due.

☐ I cannot seem to get big assignments or projects done by the due date.

☐ I find it hard to stay focused -

☐

All the time ☐ When I am… ___________________________________

☐ I get overwhelmed by all the:

☐

Sounds ☐ Sights ☐ Noises at school

☐ I find it hard to control my frustration or anger.

☐

I feel overwhelmed whenever I start a new task or chore.

Section 504 Manual 12

What Helps Me Most (Only check what helps)

☐

Being in a room with little noise and/or few distractions.

☐ Having the following read to me –

☐

Textbooks ☐ Assignments ☐ Tests

☐ Having large assignments broken into small parts.

☐ Watching a recording of the lesson.

☐ Getting assignments (not tests) ahead of time

☐

Studying –

☐

In a group ☐ By myself ☐ With an adult

☐ An adult checking with me on my progress –

☐

Beginning ☐ Middle

☐ Reviewing class notes and study guides –

☐

The notes I make ☐ The teacher’s notes

☐ Asking questions or asking for help –

☐

From the teacher ☐ From another student

☐ Giving me some time to think about my response.

☐ Having extra time to complete

☐

In-class assignments ☐ Homework ☐ Tests

☐ Giving my answers by –

☐

Writing them myself ☐ Typing them ☐ Speaking them verbally

☐ An assignment tracker sheet that an adult regularly checks on

☐ Having a “cool down” process – ☐ P

lace ☐ Adult Mentor

☐ An adult noticing my triggers (see below)

Other Information

Some of my strengths are:

__________________________________________________________________________

I am having these other difficulties at school:

__________________________________________________________________________

When I am getting frustrated or triggered, you can tell by:

__________________________________________________________________________

In addition to what I checked above, the following things help me succeed:

__________________________________________________________________________

__________________________________ ______________________________

Student Signature Date

This portion completed by the Section 504 Coordinator Date Received ___________

Section 504 Manual 13

Sample Teacher Input Form

Teachers should participate in the Section 504 process where appropriate and do not

have the discretion to decline or refuse to implement any component of a Section 504

Plan. The Teacher Input Form is to aid the teacher(s) in their reflection of the student’s

challenges and strengths, but collaborative meeting attendance of the teachers is still

invaluable when determining as a team the root cause of concerns and how to address

them.

Section 504 Manual 14

Section 504 Teacher Input Form

Student Name: _____________________________ Student ID#: _________________

Teacher Name: _____________________________ Subject/Course: ______________

Performance Area

(Check the box that identifies your level of

concern for each area/skill as applicable.)

Rationale

(For each area, briefly explain the student’s ability to access the

general education instructional program.)

Attention & Concentration