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SECTION 504 SERVICE PLAN HANDBOOK
Revised July 2016
Santa Monica-Malibu Unified School District SECTION 504 SERVICE PLAN HANDBOOK
TABLE OF CONTENTS
An Overview of Section 504 ……………………………………………………….... 3
504 Checklist for Initial Evaluation ……………………………………………….….. 8 Section 504 Service Plan Forms
Form A: Request For Section 504 Evaluation …………………………………….. 10 Form B: Parent/Guardian Notice Of Section 504 Evaluation ………….…........... 12 Form C: Notice of Parent/Guardian Rights and Procedural Safeguards ……….. 14 Section 504 Service Plan Teacher Input Form ……………………………………. 18 Teacher Rating Spreadsheet ………………………………………………………... 20 Section 504 Eligibilty Meeting ……………………………………………………….. 21 Form D: Section 504 Manifestation Determination Checklist ………………….… 25 Form E: Section 504 Review/Renewal Team Meeting …………………………… 31 Form F SMMUSD 504 Accommodation Plan Distribution Notice ……………….. 35 Appendix Authorization for Use or Disclosure of Medical Information …………………..... 38 Section 504 Prior Written Notice ……………………………………………………. 39 Sample Prior Written Notice Letter to Be Used When Parent/Guardian Revokes Consent to Section 504 Services ….……………………………………………….. 42
SMMUSD Administrative Regulation …….………………………………………… 44
Santa Monica - Malibu Unified School District An Overview of Section 504
Eligibility to receive FAPE (free, appropriate public education) under Section 504 means a student has (or regarded as having) a physical or mental impairment which substantially limits one or more major life activities.
Physical or mental impairment means:
Any physiological disorder or condition, cosmetic disfigurement, or anatomical loss affecting one or more of the following body systems: neurological; musculoskeletal; special sense organs; respiratory, including speech organs; cardiovascular; reproductive; digestive; genitor-urinary; hemic and lymphatic; skin; and endocrine; or any mental or psychological disorder, such as mental retardation, organic brain syndrome, emotional or mental illness, and specific learning disabilities. This is not an exhaustive list and other disabilities may meet this standard.
Major life activities means:
Functions such as caring for one's self, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning, reading, concentrating, thinking, sleeping, eating, working and various major bodily functions including operation of the immune system, normal cell growth, digestive, bowel, bladder, neurological, brain, and reproductive functions. This is not an exhaustive list.
Referral:
When a student is exhibiting academic, attendance, social and/or behavioral problems the student's school will convene a Student Success Team (SST) meeting. The purpose of the SST is to investigate the needs of the student. This preliminary investigation may result in one of three things:
• Regular education interventions (such as Response to Instruction and Intervention)
• Referral for Section 504 Service Plan eligibility
• Referral for a special education evaluation
Any student may be referred by a parent/guardian, teacher, other school employee, or community agency without going through the SST process. The student is referred to the Principal, counselor/advisor, or 504 Coordinator in Student Services. Prior to conducting an initial evaluation, the district shall obtain written parent/guardian consent and give the parent/guardian a copy of the District's notice of parent/guardian rights and procedural safeguards.
Evaluation:
• The student must be individually evaluated by the district before classifying the student as having a disability. The amount of information required is determined by the 504 team. The information obtained must be from a variety of sources and must be documented. This may include (but not limited to) testing, reports, medical records, health care plans, school records, interview, outside independent evaluations, school staff observations/concerns, parent/guardian observation/concerns, teacher recommendations, and the student concerns when appropriate.
• The team should include persons knowledgeable about the student and/or the students'
disability, the meaning of the evaluation data, and placement options.
This may include (but not limited to) teachers, nurses, counselors/advisors, therapists, school psychologist and other school staff and individuals who have knowledge or special expertise regarding the student and/or the disability.
Frequently Asked Questions about Section 504 Service Plans
What criteria are used to determine whether a student is eligible for a Section 504 Service Plan?
To meet the criteria for Section 504 protections, a child must:
• Have a potentially limiting mental or physical disability or impairment
• The student 1s disability must impair a major life activity (seeing, hearing, walking,
breathing, working, performing manual tasks, eating, sleeping, standing, lifting, bending, reading, concentrating, thinking, speaking, learning)?
• The degree of impairment must be substantial (the impairment must affect a major life activity compared to the average student of the same age/grade level in the general population)
The determination that a student is eligible for a Section 504 plan is made by a group of persons knowledgeable about the meaning of the evaluation data and placement options.
May school districts consider "mitigating measures" used by a student in de te r min in g whether the student has a disability?
School districts are no longer allowed to consider mitigating measures (except eyeglasses and contact lenses, if vision is fully correctable). The district must not consider the ameliorating effects of any mitigating measures that the student is using. Examples of mitigating measures are: medication, medical supplies, and low vision devices, hearing aides and cochlear implants, mobility devices, oxygen therapy, assistive technology, accommodations, aids or services, learned behavioral or adaptive neurological modifications. An impairment that is episodic or in-remission is a disability if it would substantially limit a major life activity when active.
Are there impairments which automatically mean that a student has a disability under Section 504?
No. The impairment must substantially limit one or more major life activity. Can a medical diagnosis suffice as an evaluation for the purpose of providing FAPE?
No. A physician's medical diagnosis may be considered among other sources in evaluating a student. School districts are required to draw upon a variety of sources.
What if a parent refuses to consent to an initial evaluation?
A school district must evaluate a student prior to providing services under Section 504. School districts may use due process hearing procedures to seek to override the parents' denial of consent.
Is parent permission required to evaluate a student for Section 504 eligibility?
Yes, parent permission is required for initial evaluation for Section 504 eligibility. If parent and/or staff feel the student may meet the criteria for Special Education/IEP please contact the school psychologist or the Department of Special Education.
Do temporary impairments constitute a disability under Section 504?
Transitory and minor impairments (actual or expected duration of 6 months or less) do not constitute a disability.
How often should a Section 504 Service Plan be reviewed?
The Section 504 Service Plan should be reviewed on an annual basis, at which time the parent/guardian should receive a copy of the District's notice of parent/guardian rights and procedural safeguards. A re-evaluation must be done prior to a significant change of placement, transferring a student from one type of program to another or terminating or significantly reducing a service. Parents must be notified of any changes.
Are there situations when it is inappropriate to offer a Section 504 Service Plan?
Eligibility for a Section 504 Service Plan is decided by evaluating the student and determining if the student has a physical or mental impairment that substantially limits one or more major life activities. If any of the three criteria is not met, then a Section 504 Service Plan will not be developed for the student. Keep in mind that while a Section 504 Service Plan might not be appropriate, other kinds of accommodation plans may be appropriate.
Some common misuses of a Section 504 Service Plan are outlined below:
• A parent-guardian and/or doctor presents the school with a disability diagnosis and a Section 504 Service Plan is written without first determining if the disability causes substantial limitation of a major life activity.
• A student is placed on a Section 504 Service Plan solely because the parent/guardian wants the student to have additional time on college qualifying examinations (e.g., ACT, SAT).
• A student is placed on a Section 504 Service Plan because the student has a record
of impairment or is regarded as being impaired, but the student does not actually have a disability that substantially limits a major life activity.
• A student fails to qualify for special education and related services under the IDEA, but is automatically provided with a Section 504 Service Plan.
• A student is automatically placed on a Section 504 Service Plan when the student no longer qualifies for special education services under the IDEA without first qualifying based on Section 504 criteria.
• A student is placed on a Section 504 Service Plan as an alternative way to receive special education and related services because the parent/guardian refuses to "label" his/her child by including him/her in a special education program; this may also apply in cases where parent-guardian has revoked consent to special education.
Are there any special rules regarding discipline and students with Section 504 Service Plans?
In disciplinary situations, students who have a Section 504 Service Plan may be suspended or placed in an alternative interim setting to the same extent these options would be used for children without disabilities. School personnel may also consider any unique circumstances on a case-by-case basis when determining whether a change in placement (in this context a disciplinary removal) is appropriate for a child with a disability who violates a code of student conduct. This change of placement may be to an appropriate interim alternative education setting, another setting, or suspension for not more than ten (10) consecutive school days. Additionally, removals of not more than ten (10) consecutive school days in the same school year for separate incidents of misconduct may be made.
After a child with a disability has been removed from his or her current placement for ten (10) school days in the same school year, during any subsequent days of removal, the child is entitled to a manifestation determination. This meeting must be held within ten (10) school days of the District's decision to change the student's placement. The child's parent/guardian must be invited to participate as a member of this manifestation determination meeting. At this meeting, the team will determine (based upon a review of all relevant information in the student's cumulative and Section 504 Service Plan files, the Student's Section 504 Service Plan, any teacher observations, and any relevant information provided by the parent/guardian) whether the student's alleged behavior was a manifestation of his/her disability by answering the inquiry required by the IDEA. A manifest determination meeting must also be held for student with a Section 504 Services Plan who is recommended for expulsion.
The manifest determination questions are:
• Was the conduct in question caused by, or had a direct and substantial relationship to
the student's disability; or, • Was the conduct in question the direct result of District's failure to implement the
student's current Section 504 Service Plan? If the team answers yes to either question, the alleged misconduct shall be determined to be a manifestation of the student's disability.
However, if the team answers no to both questions, the alleged misconduct shall be determined not to be a manifestation of the student's disability and the District may take disciplinary action
against the student in the same manner as it would with a child without disabilities. If the student's behavior is determined to be a manifestation of his or her disability, the District must conduct a functional behavior assessment, and implement a behavioral support plan for the student. In this situation, if a behavioral support plan has already been developed, the District will review the plan and modify it as necessary to address the behavior in question.
However, regardless of whether a student's behavior was a manifestation of the student's disability, the District may determine, following assessment, that a change of placement is appropriate for the student. The District may proceed with this change of placement following notice to the parents; consent is not required for a change of placement pursuant to Section 504.
A manifest determination meeting must be held for a student with a Section 504 Services Plan who is recommended for expulsion.
Procedural Checklist for Initial Section 504 Evaluation
□ Request For Section 504 Evaluation with Parent Signature
□ Parent/Guardian Notice of Section 504 Evaluation
□ Procedural Safeguards given to parent/guardian
□ Teacher Feedback forms returned
□ All reports, evaluations, medical reports etc. collected and reviewed
□ 504 team members invited to meeting
□ If student is found eligible, the school site shall enter student's 504 eligibility status into student information system/ Illuminate (do not enter an "end" date)
□ Teachers/staff provided with copy of accommodations (Service Plan only) and obtain their signatures on the 504 Accommodation Plan Distribution Notice
□ Keep the 504 plan at the school site in the student cum file
SECTION 504 FORMS
Form A
REQUEST FOR SECTION 504 EVALUATION Student Name Student ID # Grade DOB Gender M F School Parent Name(s) Address Home Phone Business Phone Requested by Title/Relationship: parent teacher other Student need/area of concern: I. Does the student have a physical or mental impairment, which may substantially limit a major life activity?
(Check all that apply):
Caring for one’s self Performing manual tasks Walking Hearing Breathing Working Speaking Learning Other (explain)
II. Additional comments: III. Other (current medical records/information and medical release form):
I/We request that (student) be evaluated for eligibility under section 504 of the Rehabilitation Act of 1973. Name Name Signature _____________________________________________ Date_______________________ Signature _____________________________________________ Date_______________________ Received by ___________________________________________ Date ______________________
SUBMIT TO THE SCHOOL SECTION 504 DESIGNEE
AND ATTACH ANY ADDITIONAL DOCUMENTATION
Form A
Formulario A
SOLICITUD EVALUACION SECCION 504 Nombre del Estudiante Numero de Identificación del Estudiante Grado Fecha de Nacimiento Genero M F Escuela Nombre(s) del Padre(s) Domicilio Teléfono de Casa Teléfono del Trabajo Solicitado por Titulo/Relación: Padre Maestro Otro Necesidad/área de preocupación por el estudiante: IV. ¿Tiene el estudiante una discapacidad física o mental, cual lo limita sustancialmente de una gran actividad de
vida? (Marque todo lo que aplica):
Cuidarse por si mimo Hacer deberes manuales Caminar Oír Respirar Trabajar Hablar Aprender Otro (explique)
V. Comentarios adicionales: VI. Otro (registros médicos/ información resiente y formulario de permiso para entregar registros médicos):
Yo/Nosotros pedimos que (estudiante) sea evaluado para ser elegible bajo la Sección 504 como se refiere a la ley de rehabilitación de 1973 (Rehabilitation Act of 1973). Nombre Nombre Firma _____________________________________________ Fecha_______________________ Firma _____________________________________________ Fecha _______________________ Recibido por__________________________________________ Fecha _______________________
ENTREGUE A LA PERSONA DESIGNADA DE SECCION 504
E INCLUYA TODA DOCUMENTACION ADICIONAL
Formulario A
Form B
PARENT/GUARDIAN NOTICE OF SECTION 504 EVALUATION Student Name School
Date Notice (Form B) and Rights (Form C) Sent on
Dear Parent/Guardian :
A request has been made for a Section 504 Evaluation under the Rehabilitation Act of 1973. The purpose of the evaluation is: 1. To determine whether your child has a physical or mental impairment which may be substantially limiting one or
more major life activities (e.g., walking, seeing, hearing, speaking, breathing, learning, working, caring for one’s self, performing manual tasks, eating, sleeping, standing, lifting, bending, reading, concentrating, thinking, speaking).
2. To develop a special accommodation plan so that your child can have access to and receive an appropriate
education if he/she is determined to be handicapped under Section 504. Members of the School Section 504 Team, consisting of teachers, counselors, psychologists, and administrators, will review records, interview those knowledgeable about your child, participate in observations, and collect other data. Please provide copies of any current medical, psychological, outside tutoring and/or other records to the School Section 504 Designee, , for consideration, no later than . The Section 504 Evaluation Review meeting will be held on: Date Time Place Although it is not required by law, you are invited to participate in the evaluation meeting. If you are not able to attend, please check one of the following choices: _____ I will attend the meeting. _____ I will not attend the meeting. You will receive a copy of the results of the meeting. _____ I have received a copy of the Section 504 Parent/Guardian/Student Rights and Procedure Safeguards (Enclosed) ____________________________________________________ __________________________ Parent/Guardian Signature Date PLEASE SIGN AND SUBMIT THIS FORM AND THE PARENT/GUARDIAN/STUDENT RIGHTS AND PROCEDURAL SAFEGUARDS FORM TO THE SCHOOL SECTION 504 DESIGNEE ______________________________________, NO LATER THAN _________________. Name of Designee Date Form B
Forma B
AVISO A PADRES O TUTORES DE LA EVALUACIÓN SECCIÓN 504 Nombre del alumno Escuela
Fecha del Aviso (Forma B) y Derechos (Forma C) enviados el
Estimado Padre/Tutor :
Se ha solicitado una Evaluación Sección 504 de acuerdo a la Ley de Rehabilitación de 1973. El propósito de la evaluación es: 1. Determinar si su hijo tiene un impedimento físico o mental el cual pueda limitar una o más de las actividades
principales de su vida (por ej., el caminar, ver, oir, hablar, respirar, aprender, trabajar, atenderse a sí mismo, desempeñar labores manuales, doblarse, pensar, levantar, concentrar, ver, comer, dormir, ponerse de pie, y/o leer).
2. Desarrollar un plan de ajuste especial para que su hijo tenga acceso y reciba la educación apropiada si se determina
que él o ella está incapacitado de acuerdo a la Sección 504. Miembros del Equipo Escolar de la Sección 504 consiste de maestros, asesores o consejeros, psicólogos y administradores, que verán los documentos, entrevistarán a personas que conozcan a su hijo, participarán en observaciones y recopilarán otros datos. Por favor provea copias de documentos médicos recientes de psicológicos, de tutoría especial y/u otros documentos al designado de la Sección 504 de la escuela para consideración, a más tardar el . Sección 504 la Evaluación la junta para tratar se llevará a cabo: Fecha Hora Lugar Aunque no se requiere por ley, usted está invitado a participar en la junta de evaluación. Si no puede asistir, por favor marque uno de los siguientes: _____ Si podré asistir a la junta. _____ No podré asistir a la junta. Recibiré una copia de los resultados de la junta. _____ He recibido una copia de los Derechos y Procedimientos de Protección del Padre/Tutor/Estudiante de acuerdo a la Sección 504 (Adjuntos) ____________________________________________________ __________________________ Firma del Padre /Tutor Fecha POR FAVOR FIRME Y ENVÍE ESTA FORMA JUNTO CON LA FORMA DE LOS DERECHOS Y PROCEDIMIENTOS DE PROTECCIÓN DEL PADRE/TUTOR/ESTUDIANTE AL DESIGNADO DE LA SECCIÓN 504 DE LA ESCUELA_______________________________, A MÁS TARDAR EL ________________. Nombre de al Designado Fecha Forma B
Form C ___________________________________________________________
SECTION 504 PARENT/GUARDIAN/STUDENT RIGHTS AND
PROCEDURAL SAFEGUARDS Section 504 is a federal law, which prohibits discrimination against students with a disability. This law defines an individual with a disability as anyone who exhibits any of the following conditions:
1. A mental or physical impairment which substantially limits one or more major life activities. These major life activities include but are not limited to caring for one’s self, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning, working, eating, sleeping, standing, lifting, bending, reading, concentrating, thinking, speaking.
2. A record of such impairments as described above.
3. The individual is regarded as having such impairment as previously described. You have the right to: • Have your child participate in, and receive benefits from, public education
programs without discrimination because of his/her disability;
• Receive written notice of the District’s intent to identify, evaluate, and/or provide Section 504 accommodations for your child;
• Have your child receive accommodations if he/she meets Section 504 criteria; • Have your child receive a free and appropriate public education which includes the right to be educated with
students without disabilities to the maximum extent appropriate; • Have evaluation and educational decisions made based on a variety of information sources and by persons
who know the student and who are knowledgeable about the evaluation data and Section 504 accommodations;
• Have your child be given an equal opportunity to participate in non-academic and extra-curricular activities
offered by the District; • Review all relevant records regarding your child and obtain copies of those records; • Have periodic reviews and re-evaluations before any significant changes in placement; • Use the school site and district complaint procedure to file a grievance; • Request an impartial hearing if you disagree with your child’s identification, evaluation, or educational
accommodation(s), with opportunity for participation in the hearing and representation by an attorney at parent’s/guardian’s expense.
I hereby acknowledge receipt of this information regarding my parent/guardian rights, responsibilities, and procedural safeguards under Section 504 regarding: Student Name School Grade Parent/Guardian Signature __________________________________________ Date __________________ Parent/Guardian Signature __________________________________________ Date __________________ Section 504 Designee Signature ______________________________________ Date __________________ If you should disagree with the Section 504 decision regarding your child and have a need for further information or assistance with filing a grievance or requesting an impartial hearing, please contact: School District, Section 504 Designee.
Form C
Forma C
DERECHOS Y PROCEDIMIENTOS DE PROTECCIÓN DEL PADRE/TUTOR/ESTUDIANTE DE LA SECCIÓN 504
La Sección 504 es una ley federal que prohíbe la discriminación de alumnos con alguna incapacidad. Esta ley define a un individuo con una incapacidad como alguien que muestra alguna de las siguientes condiciones: 1. Un impedimento mental o físico que limita substancialmente una o más de las actividades importantes de la
vida. Estas actividades importantes de la vida incluyen pero no están limitadas al cuidado de uno mismo, a realizar destrezas manuales, a caminar, ver, oír, hablar, respirar, aprender y trabajar.
2. Un registro de los impedimentos descritos arriba. 3. El individuo es considerado como alguien que tiene un impedimento como los que se describieron
previamente. Usted tiene el derecho de: • Que su hijo participe y reciba los beneficios de los programas de educación pública sin discriminación por
su incapacidad; • Recibir aviso por escrito del intento del Distrito para identificar, evaluar y/o proporcionar a su hijo con los
ajustes provistos por la Sección 504. • Que su hijo reciba los ajustes necesarios si él o ella llena los requisitos de los criterios de la Sección 504; • Que su hijo reciba una educación pública gratis y apropiada lo cual incluye el derecho a ser educado con
alumnos sin incapacidades siempre que sea posible; • Tener evaluaciones y decisiones educativas hechos en base a una variedad de fuentes informativas y por
personas que conocen al alumno y quienes tienen conocimiento relativo a los datos de la evaluación y los ajustes de la Sección 504;
• Que se le dé a su hijo igual oportunidad para participar en las actividades no académicas y extra curriculares
que ofrece el Distrito; • Revisar todos los documentos importantes relacionados con su hijo(a) y obtener copias de esos documentos; • Tener revisiones y re-evaluaciones periódicas antes que sucedan cambios significativos en las ubicaciones; • Usar los procedimientos de la escuela y el Distrito para entablar una querella; • Solicitar un audiencia imparcial si usted no está de acuerdo con la identificación, evaluación o
acomodación(es) educativas de su hijo, con oportunidad de participar en la audiencia y estar representado por un abogado a expensas del padre o tutor.
Acuso recibo de esta información relativa a los derechos, responsabilidades y procedimientos de protección de acuerdo con la Sección 504 referente a: Nombre del alumno: Escuela Grado Firma del Padre /Tutor _______________________________________ Fecha _________________ Firma del Padre /Tutor _____________________________________ Fecha ________________ Firma de la persona designada de la Sección 504:____________________ Fecha _________________ Si usted no está de acuerdo con la decisión de la Sección 504 referente a su hijo o hija y desea obtener más información o ayuda para entablar una querella o para solicitar una audiencia imparcial, por favor póngase en contacto con la persona designada de la Sección 504 en la oficina al (número de teléfono). Forma C
Santa Monica-Malibu Unified School District SECTION 504 SERVICE PLAN TEACHER INPUT FORM
(To be completed as part of referral and/or evaluation for a Section 504 Service Plan)
Student: Teacher: Class: Date:
This student is being reviewed for possible intervention. Please respond to each item, indicating your observations of this student and his/her school functioning. The information will be utilized in support planning for this student. Area(s) of Concern: Current grade/performance:
What do you think are his/her strengths?
What do you think are his/her challenges?
Have you provided any accommodations or modifications to better support this student’s educational/behavioral/emotional needs? If so, what were they? Did you provide these to all students in the class? ☐ Yes ☐ No
What were the results of this effort?
RATING SCALE BASED ON AREA(S) OF CONCERN:
1= Never 2= Almost Never 3 = Sometimes 4 = Often 5 = Always N = N/A
1 2 3 4 5 N 1 2 3 4 5 N Follows directions Brings materials to class
Stays on task without redirection Participates in class discussions
Has strong note-taking skills Completes tests in allotted time Awake and alert in class Completes long-term assignments Stays focused and on-task Has appropriate peer/adult relationships Strong overall effort and attitude
Turns assignments in on time Completes homework Follows directions when completing assignments Handles frustration well when he/she doesn’t understand the material Can complete assignments without assistance
Comments and/or observations regarding area of concern for student. RETURN THIS FORM TO in ROOM BY .
Your feedback may be shared directly with students and parents.
Santa Monica-Malibu Unified School District FORMULARIO DEL MAESTRO DEL PLAN DE SERVICIO SECCION 504
(Para ser completado como parte de una referencia y/o evaluación para un Plan de Servicio Sección 504)
Estudiante: Maestro: Clase: Fecha:
Este estudiante está siendo evaluado para una posible intervención. Por favor responda a cada artículo, indicando sus observaciones del estudiante y su funcionamiento escolar. La información será utilizada para dar apoyo a la planificación para este estudiante. Área(s) de Preocupaciones: Grado Actual/Nivel de desempeño:
¿Qué piensa son las fortalezas del estudiante?
¿Qué piensa son las retas?
¿Ha proveído alguna acomodación o modificación para mejor apoyar a este estudiante en su necesidades escolares/de comportamiento/emocionales? Si es así, ¿que fueron? ¿Proveyó esto a todos los estudiantes en la clase? ☐ Si ☐ No
¿Que fueron los resultados de estos esfuerzos?
ESCALA DE PUNTAJE BASADA EN AREA(S) DE PREOCUPACION:
1= Nunca 2= Casi nunca 3= En veces 4= Frecuente 5= Siempre N = N/A (no aplica)
1 2 3 4 5 N 1 2 3 4 5 N Sigue instrucciones Trae útiles a la clase
Hace su trabajo sin ser redirigido Participa en las discusiones
Toma notas con alta habilidad Completa exámenes en tiempo Despierto y alerta en clase Completa trabajos grandes Mantiene enfoque Tiene relaciones apropiadas con compañeros/adultos Fuerte esfuerzo y actitud de la clase
Entrega sus trabajos a tiempo Completa tarea Sigue las instrucciones cuando hace su trabajo Maneja bien su frustración Cuando no entiende el material Puede completar trabajo sin asistencia
Comentarios y/o observaciones con respecto a la área de preocupación del estudiante. ENTREGUE ESTE FORMULARIO A EN SALON PARA ESTA FECHA .
Teacher Rating Spreadsheet Follows
directions Brings materials to class
Has strong note taking skills
Completes test in allotted time
Awake and alert in class
Complete long term assignments
Stays focused and on task
Has appropriate peer/adult relationships
Strong overall effort and attitude
Stays on task without redirection
Participates in class discussion
Turns in assignments on time
Completes homework
Follows directions when completing assignments
Handles frustration well when he/she doesn't understand material
Can complete assignments without assistance
1
2
3
4
5
6
7
8
9
10
Average #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
Section 504 Eligibilty Meeting
Meeting Date: Click here to enter a date. I. General Information Student’s Name
ID
Grade
School/House
Advisor/Counselor/Admin
Eligibility Team Members (Names and relation to student):
Sources of evaluation information (indicate each one used):
Aptitude and/or achievement test Adaptive behavior Teacher feedback Other (specify): Click here to enter text.
1. Specify mental or physical impairment
(as recognized in DSM-IV or other respected source if not excluded under 504/ADA, e.g., illegal drug use)
Impairment: Click here to enter text.
2. What major life activities or major bodily functions does the impairment limit?
seeing hearing walking breathing learning
manual tasks reading thinking concentrating communicating
eating sleeping bowel functions bladder functions digestive functions
or specify alternative or equivalent scope and importance Click here to enter text.
3. Place an “X” on the following scale to indicate the specific degree of the impairment compared to the average student in the general population (i.e. nationwide):
Extremely Substantially Moderately Mildly Negligibly
*If the team’s determination for #3 was less than Moderate, provide notice to the parents of their procedural rights, including an impartial hearing. If the team’s determination was Substantial or above, the team should determine and list specific accommodations. II. Summary of Findings
The Section 504 Service Plan team’s review of relevant information and eligibility criteria indicates:
The student is not eligible for a Section 504 Service Plan and will continue to receive regular education resources and programs.
The student is eligible for a Section 504 Service Plan. *If you disagree with the Section 504 Service Plan team’s decision, please contact the District’s Section 504 Administrator at 310-450-8338 to discuss your concerns, or consult your Notice of Parent/Guardian Rights and Procedural Safeguards under Section 504 for other options
Extremely (Never) Substantially
Moderately (Sometimes)
Mildly (Often) Negligbly (Always)
Section 504 Eligibilty Meeting
Student Name: ID:
I have received the Sec. 504/ADA Procedural Safeguards along with a copy of this Plan
__________________________________ ______________ Parent Signature Date
If you should disagree with the Section 504 decision regarding your child and have a need for further information or assistance with filing a grievance or requesting an impartial hearing, please contact: School District, Section 504 Designee.
Signatures of Persons in Attendance Printed Name:
Title:
Signature: Date:
Printed Name:
Title:
Signature: Date:
Printed Name:
Title:
Signature: Date:
Printed Name:
Title:
Signature: Date:
Printed Name:
Title:
Signature: Date:
Printed Name:
Title:
Signature: Date:
Printed Name:
Title:
Signature: Date:
Printed Name:
Title:
Signature: Date:
Printed Name:
Title:
Signature: Date:
Section 504 Eligibilty Meeting
SECTION 504 PARENT/GUARDIAN/STUDENT RIGHTS AND PROCEDURAL SAFEGUARDS
Section 504 is a federal law, which prohibits discrimination against students with a disability. This law defines an individual with a disability as anyone who exhibits any of the following conditions:
4. A mental or physical impairment which substantially limits one or more major life activities. These major life activities include but are not limited to caring for one’s self, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning, working, eating, sleeping, standing, lifting, bending, reading, concentrating, thinking, speaking.
5. A record of such impairments as described above. 6. The individual is regarded as having such impairment as previously described.
You have the right to: • Have your child participate in, and receive benefits from, public education
programs without discrimination because of his/her disability; • Receive written notice of the District’s intent to identify, evaluate, and/or provide Section 504
accommodations for your child; • Have your child receive accommodations if he/she meets Section 504 criteria; • Have your child receive a free and appropriate public education which includes the right to be
educated with students without disabilities to the maximum extent appropriate; • Have evaluation and educational decisions made based on a variety of information sources and by
persons who know the student and who are knowledgeable about the evaluation data and Section 504 accommodations;
• Have your child be given an equal opportunity to participate in non-academic and extra-curricular activities offered by the District;
• Review all relevant records regarding your child and obtain copies of those records; • Have periodic reviews and re-evaluations before any significant changes in placement; • Use the school site and district complaint procedure to file a grievance; • Request an impartial hearing if you disagree with your child’s identification, evaluation, or
educational accommodation(s), with opportunity for participation in the hearing and representation by an attorney at parent’s/guardian’s expense.
Section 504 Elibility Meeting
Student Name: ID: Effective Date:
Area(s) Impairment Necessary Accommodations Person(s) Responsible
FORM D______________________________________________________________________
SECTION 504 MANIFESTATION DETERMINATION CHECKLIST
Student Name Student ID
School DOB Age Gender Male Female
Parent Name(s)
Address
Home Phone Work/ Cell Phone
Documents to be Reviewed:
o Evaluation and Diagnostic Results o 504 Accommodation Plan o Behavior Intervention Plan o Functional Behavior Assessment o Observations of Student o Parent Information o Discipline Record o Expulsion Packet o Other
Discipline History
Current disciplinary incident:
Education Code 48900 violation(s)
Education Code 48915 findings(s)
Use or possession of illegal drugs or alcohol: Yes No (*If yes, the student is not entitled to a manifestation determination, and may be disciplined in the same manner as a nondisabled student would be disciplined for use or possession of illegal drugs or alcohol.)
Disciplinary actions during the current school year (incidents, suspensions, etc.):
Adequate Notice (If yes, provide date of notice. If no, the conference is discontinued.)
Has the parent received adequate notice of this meeting: No Yes
Has the parent received a copy of the Section 504 rights and procedural safeguards?
No Yes
Manifestation Determination Consideration Questions:
1. Was the student’s conduct caused by, or had a direct and substantial relationship to his/her disability? How? (Pertinent questions to consider include: Did the disability impair the student’s ability to understand the impact and consequences of the behavior: Did the disability impair the student’s ability to control the behavior?)
2. Was the student’s conduct the direct result of the district’s failure to implement the Section 504 plan? How? (Pertinent questions to consider include: Was the student’s placement appropriate? Was the Accommodation Plan appropriate? Were the Accommodation Plan services provided? Were positive behavior interventions provided consistent with the 504 plan?)
Section 504 Team Decision
The conduct is a manifestation of the disability
The conduct is not a manifestation of the disability.
________________________________ ______________________________ ______________ Name/Position Signature Date ________________________________ ______________________________ ______________ Name/Position Signature Date _______________________________ _______________________________ ______________ Name/Position Signature Date ________________________________ ______________________________ ______________ Name/Position Signature Date ________________________________ ______________________________ ______________ Name/Position Signature Date ________________________________ ______________________________ ______________ Name/Position Signature Date
Parent/ Guardian Participation Signature:
I have received, reviewed, and understand this checklist and the attached rights afforded by Section 504 of the Rehabilitation Act of 1973.
Parent/ Guardian Signature_____________________________________Date_______________
Parent/ Guardian Signature_____________________________________Date_______________
If parent was not in attendance, the Manifestation Determination Checklist was sent to parent on_________________________________.
Received by:______________________________________ Date________________________
Form D
FORMULARIO D_______________________________________________________________
SECCION 504 LISTA DE MANIFESTACION DE DETERMINATION
Nombre del estudiante # IDEN
Escuela Fecha de nacimiento Edad Género masculino femenino
Nombre del padre/ padres
Domicilio
Teléfono del hogar Teléfono del trabajo/móvil
Documentos para revisión:
o Resultados de Evaluación y Diagnósticos o Plan de Acomodaciones de acuerdo al Plan 504 o Plan para Intervención de Conducta o Evaluación de la Conducta Funcional o Observaciones del Estudiante o Información del Padre o Registro de Disciplina o Paquete de Expulsión o Otro
Historial de Disciplina
Incidente Actual de Disciplina:
Violación(es) Código de Educación 48900
Conclusión(es) Código de Educación 48915
Uso o posesión de drogas ilegales o alcohol: Si No (*Si es así, el estudiante no tiene derecho a una manifestación de determinación, y puede ser disciplinado en la misma manera que un estudiante sin alguna discapacidad, y seria disciplinado por uso o posesión de drogas o alcohol.)
Acciones disciplinarias durante el año escolar actual (incidentes, suspensiones, etc.):
Notificación Adecuada (Si es así, provea la fecha de la notificación. Si no es así, la conferencia se descontinua.)
¿A recibido el padre notificación con tiempo suficiente para esta junta? No Si
¿A recibido una copia de los derechos de la Sección 504 y Seguridades Procedurales?
No Si
Preguntas que considerar para la Manifestación de Determinación:
3. La conducta del estudiante ¿fue causada por, o fue relacionada directamente o substancialmente por su discapacidad? ¿Cómo? (Preguntas pertinentes que considerar incluyen: ¿Impidió la discapacidad al estudiante la habilidad de comprender el impacto y las consecuencias de su comportamiento?; ¿impidió la discapacidad al estudiante la habilidad de controlar su comportamiento?)
4. La conducta del estudiante, ¿fue directamente el resultado de la falta del distrito de implementar el Plan Sección 504? ¿Cómo? (Preguntas pertinentes que considerar: La conducta del estudiante ¿fue directamente el resultado de la falta del distrito de implementar el Plan Sección 504? ¿Fue apropiado el Plan de Acomodaciones? ¿Fueron dados los servicios del Plan de Acomodaciones? ¿Fueron las intervenciones para la conducta consistente con el plan 504?
5. Sección 504 Decisión del Equipo
La conducta es una manifestación de la discapacidad.
La conducta no es una manifestación de la discapacidad.
________________________________ ______________________________ ______________ Nombre/Posición Firma Fecha ________________________________ ______________________________ ______________ Nombre/Posición Firma Fecha ________________________________ ______________________________ ______________ Nombre/Posición Firma Fecha ________________________________ ______________________________ ______________ Nombre/Posición Firma Fecha ________________________________ ______________________________ ______________ Nombre/Posición Firma Fecha ________________________________ ______________________________ ______________ Nombre/Posición Firma Fecha
Firma del Padre/Tutor por su Participación:
Yo e recibido, revisado, y comprendo esta lista y los derechos provistos por la Sección 504 de el Acto de Rehabilitación de 1973.
Padre/ Tutor Firma__________________________________________Fecha_______________
Padre/ Tutor Firma__________________________________________Fecha_______________
Si el padre no estaba presente, la Lista de Manifestación de Determinación, fue enviada al padre/tutor en esta fecha .
Recibido por:______________________________________ Fecha_______________________
FORMULARIO D
FORM E__________________________________________________________________________
SECTION 504 REVIEW/RENEWAL TEAM MEETING
Date Click here to enter a date. Time a.m. /p.m.
PARTICIPANTS:
Student Name Date of Birth
School Grade ID#
Parent/Guardian Name
Address
Contact Number Home Cell Work
REVIEW OF INFORMATION
CHANGES SINCE THE PREVIOUS REVIEW
PARENT STATEMENT/ 504 TEAM RESPONSE
PARENT NOTIFICATION/ RIGHTS:
I was notified of the Section 504 Review Meeting
I received the Parent/ Guardian Student Rights and Procedural Safeguards
Parent/ Guardian Signature_______________________________________Date_____________
SECTION 504 TEAM EVALUATION – DECISION
A Section 504 Plan was deemed appropriate to serve the needs of your child.
It was determined that the criteria for a Section 504 Plan was not met at this time.
SIGNATURES OF TEAM MEMBERS
______________________________________ _______________________________________ Name/ Title Name/ Title ______________________________________ _______________________________________ Name/ Title Name/ Title ______________________________________ _______________________________________ Name/ Title Name/ Title Date: ________________________________________
SIGNATURE OF PARENT/GUARDIAN
I agree with the decision of the Section 504 Team.
I disagree with the decision of the Section 504 Team.*
Parent/Guardian Signature___________________________________ Date________________
*If you do not agree with this decision, you may appeal in writing within five days to the School Section 504 Designee name and contact information). If your appeal is not resolved, you may file a complaint with the District Section 504 Designee (name and contact information).
Form E
FORMULARIO E_______________________________________________________________
JUNTA DEL EQUIPO SECCION 504 REVISION/RENOVACION
Fecha Click here to enter a date. Hora a.m./p.m.
PARTICIPANTS:
Nombre del estudiante Fecha de nacimiento
Escuela Grado # IDEN
Nombre del Padre/Tutor
Domicilio
Numero de Contacto Hogar Móvil Trabajo
REVISION DE INFORMACION
CAMBIOS DESDE LA ÚLTIMA REVISION
COMENTARIOS DEL PADRE/ RESPUESTA DEL EQUIPO 504
NOTIFICACION DEL PADRE/ DERECHOS:
Yo fui notificado de la Junta de Revisión de la Sección 504
Yo recibí Derechos del Padre/Tutor Estudiante y Seguros Procedurales
Firma del Padre/Tutor ______________________________________Fecha ________________
EVALUACION DEL EQUIPO SECCION 504 - DECISION
Fue determinado que un Plan de la Sección 504 servirá las necesidades de su hijo.
Fue determinado que los criterios necesarios no existen en este momento para calificar para un Plan de la Sección 504.
FIRMAS DEL LOS MIEMBROS DEL EQUIPO:
______________________________________ _______________________________________ Nombre/ Titulo Nombre/ Titulo ______________________________________ _______________________________________ Nombre/ Titulo Nombre/ Titulo ______________________________________ _______________________________________ Nombre/ Titulo Nombre/ Titulo Fecha: ________________________________________
FIRMA DEL PADRE/TUTOR
Yo estoy de acuerdo con la decisión del equipo de la Sección 504.
Yo no estoy de acuerdo con la decisión del equipo de la Sección 504.*
Firma del padre/tutor______________________________________ Fecha________________
*Si usted no está de acuerdo con esta decisión, puede apelarla por escrito entre cinco días a la persona: Designado de la Escuela de la Sección 504 . Si su apelación no se resuelve, usted puede registrar una queja con la persona: Designada del Distrito de la Sección 504 . FORMULARIO E
Form F________________________________________________________________________________
SMMUSD 504 ACCOMMODATION PLAN DISTRIBUTION NOTICE
DATE:
TO: (Indicate names of persons designated to receive copies of this 504 Accommodation Plan)
Name/Title Name/Title Name/Title Name/Title Name/Title Name/Title Name/Title Name/Title
FROM:
Attached is a copy of the 504 Accommodation Plan to be implemented as a result of the 504 Accommodation Team’s decisions regarding the following student:
STUDENT NAME: ID#
It is imperative that the accommodations written in the Accommodation Plan be fully implemented so that we are in compliance with Section 504, a federal law that establishes protections for students with disabilities.
Failure to comply with Section 504 law regarding the implementation of a Section 504 plan or the disregard of the protected rights of a student with disabilities may result in an investigation and ruling by the United States Department of Education, Office for Civil Rights. Such a ruling could result in the loss of all District federal funds as well as personal civil rights suits against District employees who fail to comply with the law.
I received a copy of the 504 Accommodation Plan for the above listed student.
_______________________________________________________________ Teacher’s Signature
Please sign and return this form to by .
Form F
Formulario F__________________________________________________________________________
SMMUSD NOTIFICACION PARA LA DISTRIBUCION DE ACOMODACIONES DEL PLAN 504
FECHA:
PARA: (Indique los nombres de las personas designadas para recibir copias de Acomodaciones del Plan 504)
Nombre/Título Nombre/Título Nombre/Título Nombre/Título Nombre/Título Nombre/Título Nombre/Título Nombre/Título
DE PARTE DE: ______________________________________________________________
Adjunta es una copia de Acomodaciones del Plan 504 cual debe ser implementado dado a la decisión del Equipo de Acomodaciones 504 para este estudiante:
NOMBRE DEL ESTUDIANTE: #IDEN
Es imperativo que las acomodaciones escritas en el Plan de Acomodaciones se implementen plenamente para estar en cumplimiento con la Sección 504 , una ley federal que establece protecciones para los estudiantes con discapacidades. El incumplimiento de la ley de la Sección 504 en cuanto a la implementación de un plan de la Sección 504 o fallo de los derechos protegidos de un estudiante con discapacidad puede dar lugar a una investigación y la decisión por el Departamento de Educación de los Estados Unidos, Oficina de Derechos Civiles . Un fallo de este tipo podría resultar en la pérdida de todos los fondos federales del distrito, así como demandas personales de los derechos civiles contra los empleados del Distrito que no cumplan con la ley.
Yo recibí una copia de Acomodaciones del Plan 504 para el estudiante mencionado:
_______________________________________________________________ Firma del Maestro
Por favor firme y regrese este formulario a para esta fecha . Formulario F
Appendix
SANTA MONICA - MALIBU UNIFIED SCHOOL DISTRICT 1651 Sixteenth Street, Santa Monica, California, 90404-3891 (310)450-8338
Department of Health Services
AUTHORIZATION FOR USE OR DISCLOSURE OF MEDICAL INFORMATION
EXPLANATION - This authorization for use or disclosure of medical information is being requested of you to comply with the terms of the Confidentiality of Medical Information act of 1981, Section 56, et. seq., California Civil Code. I hereby authorize, _________________________________________ ___________________________ Physician's Name Phone Number Hospital or Health Care provider: _________________________________________________________ Address: _______________________________________________________________________________ to furnish School Name: __________________________________________________________________________ Address: _______________________________________________________________________________ Attn: School Nurse ______________________________________________________________________ medical records and information pertaining to medical history, mental or physical condition, services rendered, or treatment of your patient: Student's Name: _____________________________________________ Date of Birth _______________ This authorization is limited to the following medical records and type of information:
• Summary of significant medical records, including health history, neurological, physical, or
emotional findings, and any recommendations for school programs.
• Other: ______________________________________________________________ The requester may only use the medical records to help plan the best educational program to meet the student's needs.
This authorization shall become effective immediately and shall remain in effect until ____________________.
(Date)
I understand the requester may not further use or disclose the medical information unless another authorization is obtained from me or unless such use or disclosure is specifically required or permitted by law. Copy requested and received: _____ Yes ______ No Initials ________ Signature: _____________________________________________ Date: _______________________ (patient/parent/legal guardian) Witness: _______________________________________________ Date: _______________________
Section 504 Prior Written Notice Following a Section 504 Service Plan Team Meeting
Date: To: _______________________________________ Address: __________________________________ Re: ______________________________________ Date of Birth: __________________________ Dear: ________________________________________ This letter is intended as a follow-up to your child's _____/_____/_____ Section 504 Service Plan team meeting. This letter serves as the Santa Monica - Malibu U.S.D.'s prior written notice regarding proposed or refused actions. The District is required to provide you with prior written notice when the District proposes to initiate or change, or refuses to initiate or change, the identification, assessment, or educational placement of the child, or the provision of a free appropriate public education to your child. On _____/_____/ , we met to review the District's current evaluation data on your child including any recent evaluations completed by the District, any evaluations or information you provided to the Section 504 Service Plan team, current classroom based assessments, work samples, and observations, and your child's teacher and other staff observations. The specific information/data used to make decisions at your child's / / Section 504 Service Plan team meeting included:
Based upon this information, the Section 504 Service Plan team discussed and the District determined/offered the following:
Eligibility (Check if appropriate and discussed at the Section 504 Service Plan team meeting):
_____ Your child is eligible for Section 504.
_____ Your child is NOT eligible for Section 504.
Eligibility options considered and why they were rejected:
Other factors relevant in the District’s proposal/refusal:
Regular or Special Education Related Aids and Services (Check if appropriate and discussed at the Section 504 Service Plan team meeting):
Based upon the information considered at your child's Section 504 Service Plan team meeting, the District determined that the following regular or special education and related aids and services are designed to meet your child's individual educational needs as adequately as the needs of his/her non-disabled peers: __________________________________________________________________________
_______________________________________________________________________________________
Other regular or special education and related aids and services considered and why they were rejected:
Other factors relevant in the District’s proposal/refusal:
Assessment: (Check if appropriate and discussed at the Section 504 Service Plan team meeting.)
The Section 504 Service Plan team considered, and the District determined, that additional assessment of your child is needed at this time. Please find attached the District's proposed assessment plan as discussed at the Section 504 Service Plan team meeting. The Section 504 team considered and the District determined that the additional assessment(s) you requested in the area(s) of __________________________________________________________ Are not necessary in determining and providing a free appropriate public education to your child. Therefore, the District will not conduct the assessment(s) you requested at this time.
Other assessment options considered and why they were rejected:
Other factors relevant in the District’s proposal/refusal:
The District requests that you return your child's signed Section 504 Service Plan and/or the enclosed assessment plan to the District as soon as possible. In addition, the District acknowledges your right to make informed decisions regarding your child's educational program. Please do not hesitate to contact me should you have any questions regarding your child's Section 504 Service Plan or need further information in order to respond to the District's proposal(s)/refusal(s) as detailed above.
Please find enclosed a copy of the District's procedural rights and safeguards under Section 504 for your review records. In addition to contacting the District, you may also contact the following agency to obtain assistance in understanding your rights:
Office for Civil Rights 90 7th Street, Suite 4-100 San Francisco, CA 94103
Thank you for your time and careful consideration in this matter. Again, if you have any questions or need further assistance, please do not hesitate to contact me at ______________________________________
Sincerely,
___________________________________________ (Signature of District Representative) ___________________________________________ (Printed Name of District Representative) ___________________________________________ (Title of District Representative) Enclosures: Notice Parent/Guardian Rights and Procedural Safeguards under Section 504 Section 504 Service Plan dated: _______/_______/_______, if appropriate Assessment Plan dated: _______/________/_______, if appropriate.
PRIOR WRITTEN NOTICE LETTER (TO BE USED WHEN PARENT/GUARDIAN REVOKES CONSENT TO SECTION 504 SERVICES)
(To be placed on District Letterhead)
U.S. Mail and Certified Mail, Return Receipt Requested {insert Date} {insert Parents’ Name & Address} Re: {insert Student’s Name} Dear {insert Parent/Guardian Name(s)}, This letter responds to your [DATE] letter, in which you revoked your consent for your child, [STUDENT NAME], to receive a Section 504 Service Plan from the [SCHOOL DISTRICT]. Please consider this the District's response to your request. [WE SUGGEST THAT THIS LETTER IS SENT NO LATER THAN 10 SCHOOL DAYS FROM RECEIPT] The District believes that [STUDENT NAME] continues to require a Section 504 Service Plan and that the plan developed at the Section 504 Service Plan team meeting on [DATE] continues to be appropriate. This Section 504 Service Plan was developed based on the following information: [SPECIFY EACH EVALUATION PROCEDURE, ASSESSMENT, RECORD, OBSERVATIONS AND/OR REPORTS]. However, based on the receipt of your written revocation of consent, the District will discontinue the implementation of all aspects of the Section 504 Service Plan for [NAME] on [DATE] [WE SUGGEST THAT THE PLAN WILL CEASE TO BE IMPLEMENTED 10 SCHOOL DAYS FROM THE DATE OF THIS LETTER]. After that date, [STUDENT NAME] will no longer receive the regular or special education and related aids and services that are contained in [his/her] [DATE(S)] Section 504 Service Plan, which include, but are not limited to: [LIST PLACEMENT, SERVICES, ACCOMMODATI ONS, MODIFICATIONS, AND/OR SUPPORTS, INCLUDING BEHAVIORAL SUPPORTS, STUDENT WILL NO LONGER RECEIVE]. Beginning on [DATE] [WE SUGGEST THE SCHOOL DAY AFTER THE DAY SPECIAL EDUCATION SERVICES STOP], [STUDENT NAME] will be placed in [DESCRIPTION OF GENERAL EDUCATION PLACEMENT] without the supports contained in his/her Section 504 Service Plan. At that time, [STUDENT NAME] will only have access to [LIST ANY SUPPORTS, ACCOMMODATIONS AND/OR OPPORTUNITIES MADE AVAILABLE TO GENERAL EDUCATION STUDENTS]. Please be advised that after [DATE], [STUDENT NAME] will become a general education student and will no longer be entitled to the regular or special education and related aids and services that are contained in [his/her] [DATE(S)] Section 504 Service Plan and the rights and procedural safeguards provided under Section 504 of the Rehabilitation Act of 1973. [STUDENT NAME] will be treated as a general education student in all respects, including discipline,[testing, and graduation, if appropriate]. As a result, [STUDENT NAME]'s disability will not be taken into consideration when determining appropriate disciplinary action and [he/she] will not be entitled to the IDEA's discipline protections. [OPTIONAL LANGUAGE: Therefore, we encourage you to consider the possible consequences of removing your child from special education.]
Your revocation of consent releases the District from liability for providing your child with a free appropriate public education. If, in the future, you would like your child to receive regular or special education and related aids and services through a Section 504 Service Plan, please contact us. The District will treat such a request as a request for an initial evaluation. The District would like to meet with you on [DATE] to discuss your decision and its potential impacts. However, you are not obligated to meet with us and any meeting will not delay or deny the discontinuation of your child's Section 504 Service Plan. Please contact my office at [INSERT CONTACT INFORMATION] to confirm that you will attend the meeting. If we do not hear from you, we will assume that you do not wish to meet. I have enclosed a copy of [STUDENT NAME]'s [DATE(S) OF MOST RECENT SECTION 504 SERVICE PLAN] Section 504 Service Plan for your reference, as well as a copy of the District's parent/guardian rights and procedural safeguards under Section 504. Please feel free to contact me with any questions you may have at this time. You may also contact the Office for Civil Rights at 90th Street, Suite 4-100, San Francisco, CA 94103. Thank you for your time and careful consideration in this matter. If you have any questions or concerns, please do not hesitate to contact me. Sincerely, [NAME] [TITLE] [SCHOOL SITE OR SCHOOL DISTRICT] Enclosures: Parent/guardian's written revocation of consent Notice of Parent/Guardian Rights and Procedural Safeguards Under Section 504 [DATE(S) OF MOST RECENT SECTION 504 SERVICE PLAN] Section 504 Service Plan
Santa Monica - Malibu Unified School District Administrative Regulation Instruction
IDENTIFICATION AND EDUCATION UNDER SECTION 504 AR 6164.6
Definitions Free appropriate public education (FAPE) under Section 504 of the Rehabilitation Act of 1973 means the provision of either regular or special education and related aids and services, designed to meet the student's individual educational needs as adequately as the needs of nondisabled students are met. (34 CFR 104.33) Eligibility to receive FAPE under Section 504 means a student has a physical or mental impairment which substantially limits one or more major life activities. (34 CFR 104.33) Major life activities means functions such as caring for one's self, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning, and working. (34 CFR 104.3) Physical or mental impairment means any of the following: (34 CFR 104.3)
1. Any physiological disorder or condition, cosmetic disfigurement, or anatomical loss affecting one or more of the following body systems: neurological; musculoskeletal, special sense organs; respiratory, including speech organs; cardiovascular; reproductive, digestive, genito-urinary; hemic and lymphatic; skin; and endocrine
2. Any mental or psychological disorder, such as mental retardation, organic brain syndrome, emotional or
mental illness, and specific learning disabilities Referral, Identification, and Evaluation 1. Any student may be referred by a parent/guardian, teacher, other school employee, student success team,
or community agency for consideration of eligibility as a disabled student under Section 504. This referral may be made to the principal or 504 Coordinator.
2. Upon receipt of a referral for eligibility, the principal or 504 Coordinator shall consider the referral and
determine whether an evaluation is appropriate. This determination shall be based on a review of the student's school records, including academic and nonacademic areas of the school program; consultation with the student's teacher(s), other professionals, and the parent/guardian, as appropriate; and analysis of the student's needs.
If it is determined that an evaluation is unnecessary, the principal or 504 Coordinator shall inform the parents/guardians in writing of this decision and of the procedural safeguards, as described in the "Procedural Safeguards" section below.
3. If it is determined that a student needs or is believed to need special education or related services under
Section 504, the district shall conduct an evaluation of the student prior to initial placement and before any significant change in placement. (34 CFR 104.35)
Prior to conducting an initial evaluation of a student for eligibility under Section 504, the district shall obtain written parent/guardian consent.
The district's evaluation procedures shall ensure that test and other evaluation materials: (34 CFR 104.35)
a. Have been validated and are administered by trained personnel in conformance with the instruction
provided by the test publishers
b. Are tailored to assess specific areas of educational need and are not based solely on a single IQ score
c. Reflect aptitude or achievement or whatever else the tests purport to measure and do not reflect the student's impaired sensory, manual, or speaking skills unless the test is designed to measure these particular deficits
Section 504 Services Plan and Placement 1. A multi-disciplinary 504 team shall be convened to review the evaluation data in order to make placement
decisions.
The 504 team shall consist of a group of persons knowledgeable about the student, the meaning of the evaluation data, and the placement options. (34 CFR 104.35)
In interpreting evaluation data and making placement decisions, the team shall draw upon information from a variety of sources, including aptitude and achievement tests, teacher recommendations, physical condition, social or cultural background, and adaptive behavior. The team shall also ensure that information obtained from all such sources is documented and carefully considered and that the placement decision is made in conformity with 34 CFR 104.34. (34 CFR 104.35)
2. If, upon evaluation, a student is determined to be eligible for services under Section 504, the team shall meet to
develop a written 504 services plan which shall specify the types of regular or special education services, accommodations, and supplementary aids and services necessary to ensure that the student receives FAPE.
The parents/guardians shall be invited to participate in the meeting and shall be given an opportunity to examine all relevant records.
3. If the 504 team determines that no services are necessary for the student, the record of the team's meeting shall
reflect whether or not the student has been identified as a disabled person under Section 504 and shall state the basis for the decision that no special services are presently needed. The student's parent/guardian shall be informed in writing of his/her rights and procedural safeguards, as described in the "Procedural Safeguards" section below.
4. The student shall be placed in the regular educational environment, unless the district can demonstrate that the
education of the student in the regular environment with the use of supplementary aids and services cannot be achieved satisfactorily. The student shall be educated with those who are not disabled to the maximum extent appropriate to his/her individual needs. (34 CFR 104.34)
5. The district shall complete the identification, evaluation, and placement process within a reasonable time frame.
6. A copy of the student's Section 504 services plan shall be kept in his/her student record. The student's
teacher(s) and any other staff who provide services to the student shall be informed of the plan's requirements.
If a student transfers to another school within the district, the principal or designee at the school from which the student is transferring shall ensure that the principal or designee at the new school receives a copy of the plan prior to the student's enrollment in the new school.
Review and Reevaluation 1. The 504 team shall monitor the progress of the student and the effectiveness of the student's Section 504
services plan to determine whether the services are appropriate and necessary and whether the student's needs are being met as adequately as the needs of nondisabled students. The team shall review the student's plan annually. In addition, the student's eligibility under Section 504 shall be reevaluated at least once every three years.
2. A reevaluation of the student's needs shall be conducted before any subsequent significant change in
placement. (34 CFR 104.35) Procedural Safeguards Parents/guardians shall be notified in writing of all district decisions regarding the identification, evaluation, or educational placement of students with disabilities or suspected disabilities. Notifications shall include a statement of their right to: (34 CFR 104.36) 1. Examine relevant records
2. Have an impartial hearing with an opportunity for participation by the parents/guardians and their counsel
3. Have a review procedure
Notifications shall also detail the parent/guardian's right to file a grievance with the district over an alleged violation of Section 504; have an evaluation that draws on information from a variety of sources; be informed of any proposed actions related to eligibility and plan for services; receive all information in the parent/guardian's native language and primary mode of communication; periodic reevaluations and an evaluation before any significant change in program/service modifications; an impartial hearing if there is a disagreement with the district's proposed action; be represented by counsel in the impartial hearing process; and appeal the impartial hearing officer's decision. If a parent/guardian disagrees with decisions regarding the identification, evaluation, or educational placement of his/her child under Section 504, he/she may request a Section 504 due process hearing in accordance with the following procedures:
1. Within 30 days after receipt of the district's decision with which the parent/guardian disagrees, the parent/guardian may request an administrative review of the decision. The 504 Coordinator shall designate an appropriate administrator to meet with the parent/guardian to attempt to resolve the issue. This review shall be held within 14 days of receiving the parent/guardian's request.
2. If the parent/guardian chooses not to request an administrative review or if the review does not resolve the
issue, the parent/guardian may request in writing a Section 504 due process hearing. The parent/guardian's request for a hearing shall be made within 30 days of receiving the district's decision or within 14 days of completion of the administrative review. The request shall include:
a. The specific nature of the decision with which the parent/guardian disagrees
b. The specific relief the parent/guardian seeks
c. Any other information the parent/guardian believes pertinent
Within 30 days of receiving the parent/guardian's request, the Superintendent or designee and 504 Coordinator shall select an impartial hearing officer. This 30-day deadline may be extended for good cause or by mutual agreement of the parties. The 504 Coordinator shall maintain a list of impartial hearing officers who are qualified and willing to conduct Section 504 hearings. To ensure impartiality, such officers shall not be employed by or under contract with the district in any capacity other than that of hearing officer and shall not have any professional or personal involvement that would affect their impartiality or objectivity in the matter. Within 45 days of the selection of the hearing officer, the Section 504 due process hearing shall be conducted and a written decision mailed to all parties. This 45-day deadline may be extended for good cause or by mutual agreement of the parties. Any party to the hearing shall be afforded the right to:
1. Be accompanied and advised by counsel and by individuals with special knowledge or training related to the problems of students who are qualified as disabled under Section 504
2. Present written and oral evidence
3. Question and cross-examine witnesses
4. Receive written findings by the hearing officer
If desired, either party may seek a review of the hearing officer's decision by a federal court of competent jurisdiction.
Notifications The Superintendent or designee shall ensure that the district has taken appropriate steps to notify students and parent/guardian of the district's duty under Section 504. (34 CFR 104.32) District Coordinator for Implementation of Section 504 The district has designated the following individual to coordinate its efforts to comply with the requirements of law, Board policy, and administrative regulation pertaining to the implementation of Section 504: 934 CFR 104.7. Director of Student Services Santa Monica-Malibu Unified School District 1651 15th Street Santa Monica, CA 90404