Name: ______, ______Student ID: ______

(Last) (First)

Student ID / Birth Date / Date
Last Name / First Name
School / Grade

The Section 504 team reviewed the following areas of eligibility:

Recent medical history ☐ Yes ☐ N/A

Academic records ☐ Yes ☐ N/A

Behavior records ☐ Yes ☐ N/A

Attendance records ☐ Yes ☐ N/A

ð  The Section 504 team determined that the current accommodations (504 plan dated ______) and/or services are appropriate and will be implemented.

ð  The Section 504 plan from ______has been revised (See attached accommodation plan). (Date)

ð  The student no longer meets eligibility requirements for Section 504.

(Document meeting on Eligibility Determination Form. Parent/guardian signature is needed below)

ð  The parent/guardian declines Section 504 accommodations and/or services.

(Parent/guardian signature is needed below)

Signature of Participants in agreement with the Section 504 Annual Review Meeting:

Role / Title / Name / Signature / Date
Parent/Guardian
Parent/Guardian
Student (if present)
Administrator
Teacher
Teacher
Site 504 Coordinator
School Social Worker
School District Nurse

Please place a copy in cum file and send a copy of this completed form to:

District 504 Coordinator, School Health Programs, 1515 Quintara St., SF, CA 94116

Annual or Interim Review Date: ______

Please check one:

☐ ADDITIONAL accommodations to Section 504 plan dated: ______

☐ REVISED accommodation plan and contains all current accommodations.

Accommodations

Specific Need: / Accommodations/Services / Start Date / End Date
Who will implement the accommodations:
Specific Need: / Accommodations/Services / Start Date / End Date
Who will implement the accommodations:
Specific Need: / Accommodations/Services / Start Date / End Date
Who will implement the accommodations:
Specific Need: / Accommodations / Start Date / End Date
Who will implement the accommodations:
Specific Need: / Accommodations / Start Date / End Date
Who will implement the accommodation:
Specific Need: / Accommodations / Start Date / End Date
Who will implement the accommodation:

I agree with the accommodations as noted above in this 504 Plan:

Role / Title / Name / Signature / Date
Parent / Guardian
Parent / Guardian
Student (if present)
Administrator
Teacher
Teacher
Teacher
Counselor
School District Nurse
School Social Worker
School Psychologist

Notice of Parent/Guardian & Student Rights given to: ______on: ______by: ______

Next Steps:

1.  Give copy of 504 Plan to parent/guardian.

2.  Give copy of 504 Plan to appropriate staff.

3.  Place a copy of 504 Plan in the student’s cum file.

4.  Send a copy of this 504 Plan to:

District 504 Coordinator, School Health Programs, 1515 Quintara St., SF, CA 94116

Form 504-5 (June 2016)