School/Class:____________________________________________

Teacher:________________________________________________

Date of Accommodation Plan:_______________________________

A). General Strengths:

B). General Weakness:

Specific Accommodations

Accommodation #1

Class:

Accommodation(s)

Person Responsible for Implementing Accommodations:

Accommodation #2:

class:

Accommodation(s)

Person Responsible for Implementing Accommodation

Accommodation #3:

Class:

Accommodation(s)

Person Responsible for Implementing Accommodation

Accommodation #4:

Class:

Accommodation(s)

Person Responsible for Implementing Accommodation

Individuals Participating in Development of Accommodation Plan:

_________________________________________________________
_________________________________________________________
_________________________________________________________

_____________________________{Parent/guardian Signature)

_____________________________(Principal Signature)

_____________________________(School 504 Coordinator Signature)