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: ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________