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    504 Plan ADHD Sample

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    hthaier4062
    This sample 504 plan provides an example of accommodations and services that could be included for a student diagnosed with ADHD. It outlines teacher education and support such as consultation with a behavior specialist and required training. The plan also lists specific accommodations in the areas of organization, distractibility, and impulsivity including writing homework in a planner, providing extra books, seating arrangements, designated work spaces, and nonverbal cues. It is noted that the plan should be tailored to the individual student's needs.

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    504 Plan ADHD Sample

    Uploaded by

    hthaier4062
    2K views2 pages
    This sample 504 plan provides an example of accommodations and services that could be included for a student diagnosed with ADHD. It outlines teacher education and support such as consultation with a behavior specialist and required training. The plan also lists specific accommodations in the areas of organization, distractibility, and impulsivity including writing homework in a planner, providing extra books, seating arrangements, designated work spaces, and nonverbal cues. It is noted that the plan should be tailored to the individual student's needs.

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    504 form

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    This sample 504 plan provides an example of accommodations and services that could be included for a student diagnosed with ADHD. It outlines teacher education and support such as consultation with a behavior specialist and required training. The plan also lists specific accommodations in the areas of organization, distractibility, and impulsivity including writing homework in a planner, providing extra books, seating arrangements, designated work spaces, and nonverbal cues. It is noted that the plan should be tailored to the individual student's needs.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    2K views2 pages

    504 Plan ADHD Sample

    Uploaded by

    hthaier4062
    This sample 504 plan provides an example of accommodations and services that could be included for a student diagnosed with ADHD. It outlines teacher education and support such as consultation with a behavior specialist and required training. The plan also lists specific accommodations in the areas of organization, distractibility, and impulsivity including writing homework in a planner, providing extra books, seating arrangements, designated work spaces, and nonverbal cues. It is noted that the plan should be tailored to the individual student's needs.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    Sample 504 Plan for ADHD

    Page 1 of 2

    There is no standard 504 plan for schools to use. This form shows you an example of what could be included in a 504 plan
    for a student who has ADHD. A 504 plan should be tailored to a childs needs. So while some of the services and
    accommodations in this sample plan may be appropriate for your child, others may not.
    Keep in mind the school is allowed to use its own form or not use a written 504 plan at all. In these cases, you can still use
    this sample plan to take notes and organize your thoughts.

    School Name: Hartleyville Middle School


    Student Name: Kevin Smith

    Date of Birth: 5/26/2004

    Qualifying Disability: ADHD

    Date Plan Written:

    Date Plan Goes Into Effect:

    9/1/16

    Date Plan to Be Reviewed:

    9/8/16

    Grade:

    9/1/17

    Documentation of Disability (see attached):


    Report from Developmental Pediatrics, dated 6/28/16; Child Behavior Checklist & Conners Rating Scales
    (from school evaluation dated 5/16/16)

    504 Team Members

    Title

    Contact Information

    Mr. Tallison

    Administrator

    [email protected]

    Ms. Anderson

    General education teacher

    [email protected]

    N/A

    Related service provider

    Mr. & Mrs. Smith

    Parent

    [email protected]

    Ms. Zicotti

    Other: Behavior specialist

    [email protected]

    Other:

    TEACHER EDUCATION AND SUPPORT


    Teachers who work with Kevin will be provided consultation time with the school behavior specialist, Ms. Zicotti.
    She will help them implement accommodations and behavior management strategies in the classroom.

    Any teacher who works with Kevin, and who isnt trained as a special educator or behavior specialist, must watch
    this 3-minute video, What Is ADHD?, available at u.org/whatisADHD.

    Teachers who work with Kevin must also review the attached articles on (1) signs of ADHD they may see in the
    classroom and (2) self-advocacy phrases for middle school students.

    Sample 504 Plan for ADHD

    Page 2 of 2

    ACCOMMODATIONS AND/OR SERVICES


    Area of Educational Need

    Accommodation
    or Service

    Person(s) Responsible
    for Implementing

    Frequency of
    Accommodation or Service

    Organization

    Write homework
    assignments in his planner
    and have his teacher(s)
    initial it.

    Student, Teacher(s)

    Daily:
    At the end of each class

    Organization

    Provide an extra set of


    books to keep at home.

    Teacher(s)

    Annually

    Distractibility

    Seat student near the front


    of the class or away from
    peer distractions.

    Teacher(s)

    Daily

    Distractibility

    Provide student with a


    quiet area for test-taking
    and in-class individual work.

    Teacher(s)

    As needed

    Impulsivity

    Give (and respond to)


    agreed-upon signals
    reminding student to raise
    his hand before answering
    or acting.

    School staff, Student

    As needed

    NOTES

    Date Approved:

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