REF-1446.3
October 17, 2012 / LOS ANGELES UNIFIED SCHOOL DISTRICT
Division of Special Education / ATTACHMENT A-1

REQUEST FOR RAPID ACCESS PROGRAM ACCESSIBILITY

FOR STUDENTS WITH DISABILITIES

INFORMATION MUST BE TYPED OR PRINTED LEGIBLY FOR FORM TO BE PROPERLY PROCESSED

School Information

School Name / Local District / Location Code
Principal Name / Email Address / Today’s Date

Student Information

Last Name, First Name / Date of Birth / Grade
Principal Name / Email Address
Student Has an Active IEP? / Yes No / Date of Active IEP
Student Has an Active 504 Plan? / Yes No / Date of Active 504 Plan

Description of Accessibility Issue"Accessibility" is the combination of various elements in a school, building, or area which allows access, circulation, and the full use of the building and facilities by persons with disabilities.

REASON FOR REQUEST FOR RAPID ACCESS PROGRAM ACCESSIBILITY (briefly describe the issue and what is preventing access):

It is the principal’s responsibility to determine if a non-renovation/modificationsolution, such as changing a classroom or adjusting a schedule can be implemented to ensure the student has access to the program. Site personnel may request assistance from the Division of Special Education in making this determination by contacting the Least Restrictive Environment (LRE) Specialist at the appropriate Special Education Service Center.

An Interim Services Plan is required to submit a “Request for Rapid Access Program Accessibility.”

Interim Services Plan

Please provide a description of the interim services plan, which will be implemented to provide temporary program access for the identified student while the request is being considered and/or until the program accessibility changes have been made:

Description of Program Accessibility Request(As indicated in the body of this Reference Guide, requests appropriate for this program are very limited. Review the content carefully prior to submitting this request for approval). Place an “X” in the box next to the type of program accessibility that is being requested and indicate the location where the requested accessibility is needed.

Type of Accessibility Modification / Location
Installation of temporary ramp
Alteration of door jam
Installation of grab bars (restroom)
Installation of adapted equipment
Removal of door
Create appropriate turning radius for wheelchair
Create appropriate opening for wheelchair
Installation of appropriate door hardware
Installation of dedicated electrical outlet
Temporary lift for stage (school must designate storage space)
Adjust water fountain to appropriate height
Other (Describe):

Principal Approval

Principal Signature / Date
Principal Name - Printed

To Be Completed By “SELPA Access Review Team”

Date Request Received: / Date Interim Services Plan Reviewed / Date Response Provided to School
Interim Services Plan Reviewed By: / Name: / Position: / Office/Unit: / Email:
Interim Services Planapproved. / Site visit needed to approve interim plan.
Interim Services Plan approved with modifications listed below.
NEEDED MODIFICATIONS TO INTERIM PLAN:
Confirmed date for SELPA Access Review Team Visit: / Name of School Contact Person:

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