CONFIDENTIAL
LDE 07/2013
SECTION 504
INDIVIDUAL ACCOMMODATION PLAN (IAP)
__________________________________________________
Local Educational Agency (LEA)
Student__________________________________ I.D. #__________________________DOB ________________Grade______
Last
First
School________________________________________504 Chairperson___________________________________________
Date of Annual IAP____________________ Date of Most Recent Section 504 Evaluation (within 3 years)__________________
Part A. Section 504 Disability (Check all that apply): Identified impairment that substantially limits one or more major life
activities: (More than one source of supporting data needed)
Characteristics of:
01 DYSLEXIA (Bulletin 1903)
Supporting Data____________________________________________________________
02 DYSGRAPHIA
Supporting Data_______________________________________________________________________
03 ADD/ADHD
Supporting Data_________________________________________________________________________
04 Other Academic/Learning Disability (Specify e.g. Dyscalculia, Central Auditory Processing)______________________
Social/Emotional Characteristics of:
05 BEHAVIOR DISORDER
Supporting Data______________________________________________________________
06 OPPOSITIONAL DEFIANT DISORDER
Supporting Data________________________________________________
07 ANXIETY DISORDER
Supporting Data________________________________________________________________
08 BIPOLAR DISORDER
Supporting Data________________________________________________________________
09 ASPERGER’S DISORDER/TOURETTE’S SYNDROME Supporting Data_____________________________________
Medical:
10 DIABETES/HYPOGLYCEMIA/OTHER RELATED DISORDER Supporting Data_____________________________
11 SEVERE ASTHMA OR OTHER RESPIRATORY CONDITION
Supporting Data_____________________________
12 SEVERE ALLERGIES OR ANAPHYLAXIS
Supporting Data _____________________________________________
13 CHRONIC FATIGUE SYNDROME
Supporting Data_____________________________________________________
14 MIGRAINE HEADACHES
Supporting Data ____________________________________________________________
15 BROKEN (expected 6+ months duration) OR MISSING BODY PART Supporting Data __________________________
16 EYE ABNORMALITY/VISION IMPAIRMENT
Supporting Data ___________________________________________
17 EAR ABNORMALITY/HEARING IMPAIRMENT
Supporting Data ________________________________________
18 DIGESTIVE OR EATING DISORDER
Supporting Data __________________________________________________
19 BLADDER DISORDER
Supporting Data________________________________________________________________
20 NEUROLOGICAL DISORDER
Supporting Data ________________________________________________________
21 CIRCULATORY/ENDOCRINE DISORDER
Supporting Data_____________________________________________
22 OTHER SYNDROME OR RARE DISEASE
Supporting Data _____________________________________________
23 DRUG OR SUBSTANCE ABUSE RELATED
Supporting Data_____________________________________________
Other:
24 SOCIAL/EMOTIONAL: OTHER (none of the above applies)
Supporting Data________________________________
25 MEDICAL: OTHER (none of the above applies)
Supporting Data___________________________________________
Accommodations are needed at this time. Yes______ No______ (If no, proceed to Parts J and K)
Altered format instructional/supplemental materials are required at this time.
Yes______ No______ (If yes, specify below)
Format needed____________________________________ Reason for Altered Format ________________________________
Behavior Intervention Plan is attached (if appropriate) Yes______ No______
Medical Plan is attached (if appropriate) Yes______ No_______
Other Relevant Documents are attached (if appropriate) Yes______ No_______
Comments/Additional Supporting Data:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________