Cedarville University

http://www.cedarville.edu/academics/education/classes/edsp202/refprocess/intervention.htm


Sample 504 Plan



Name: Ellen Smith

Date: December 10, 1999

Teacher: Miss. Megan R. Mate



School/Grade:Ledgemont High School, Second Grade

Review Date: Jun 19 99

Counselor: Mrs. Cheryl Irish Participants in the Development of the 504 Plan:

  • ?Parents
  • ?Counselor
  • ?Teacher






_________________________________

Parent Signature/Declines Program







Susan M. Smith

Parent Signature/Accepts Program

Currently on Medication Yes_____ No__X__ Physician: _NA_______________________________________



Type: _NA___________ Dosage: _NA_____________ Times: _NA_____________



Behavioral Goals Actions Taken Year End Review
Physically
  • ?Increase safety during convulsions to the point where no serious injury occurs
  • ?Create a safe area in the classroom with cushions and mats
  • ?Place an oxygen mask in the area in which her desk is located
  • ?Communicate with parents and have them monitor her at home
  • ?Create a system where a fellow student alerts the school nurse during the episodes
  • ?Be sure that all the students are aware of the severity of these convulsions and what the proper way to behave when they occur
Academically
  • ?Increase concentration when reading so that she can correctly answer 80% of comprehension questions


















  • ?Increase arts and crafts ability to the point to where she can successfully complete the project
  • ?Use books only up to twenty pages in length
  • ?Get books on tape for her to listen to
  • ?Create peer reading Groups
  • ?Have someone (fellow student of teacher's aide) read out loud to her
  • ?Have her retell the story to the teacher as a comprehension check


  • ?Provide a fat pencil for her to use while drawing or writing
  • ?Give her projects that are centered on her interests, talents, and abilities-encouraging her to finish them
  • ?Assign projects that can be completed in one setting
  • ?Integrate art into other subjects, making fewer assignments for her to complete and more time to complete them
  • ?Create art groups for her to work with
Socially
  • ?Increase her self-esteem to the point where she is comfortable around other students
  • ?Have Judy (Ellen's close friend) redirect conversations when the turn to Ellen's symptoms
  • ?Positive reenforcement for work done correctly
  • ?Do a lot of work in small groups that stay the same so she can become comfortable with at least a few students
  • ?Let her know that whenever she has problems or needs to talk, she can always come to the teacher
  • ?Emphasize the fact that everyone is special and each student has unique talents and characteristics
Behaviorally
  • ?Decrease stubbornness after seizure to the point where she is willing to actively participate in classroom activities
  • ?Make sure she is aware of the fact that participation is rewarded
  • ?Give her positive reenforcement when she does participate
  • ?Implement appropriate punishment for nonparticipation
  • ?Make schedule flexible in case these episodes occur-fun activity following incident
  • ?Allow her to go to the reading corner for ten minutes after her seizures occur to clam her down before rejoining the class