HOUSTON INDEPENDENT SCHOOL DISTRICT

SECTION 504 SERVICE PLAN

Hattie Mae White Educational Support Center
4400 West 18th Street
Houston, Texas 77092-8501
713-556-6000

Name:
Date of Birth:
CA:
Gender:
Ethnicity:

Aaron Ben-Amram Test

08/11/2010
6 Years
Male
White

ID#:
School:
Grade:
Parent:
Address:
Phone:

TESTABAT
Test School
12
Amram Test
123 Some St. Goshen, TX 12345

Section 504 Service Plan

Meeting Date: 08/20/2016

Impairments:
Eligibility Date: 11/18/2013

Begin Date:

End Date:

Reevaluation Date: 11/18/2016

Service providers or Section 504 administrator must attend meetings where services designated with an asterisk are
considered. Transportation must be submitted electronically to Section 504 Facilitator for approval.
Section 504 Services

Type of Service
Dyslexia Services

Sessions Per
3 times/Week

Time Per
Session
30 minute(s)

Hours Per
Week
1 hrs and 30
min

Section 504 Emergency Plan

Begin / End
Dates
10/07/2014 /
10/06/2015

Houston Independent School District

Test School
123 ABC St
Test, TX 55555
Phone: 123-456-7891 Fax: 112-345-1689
Student Name: Aaron Ben-Amram Test
Section 504 Student Service Plan

Student ID: TESTABAT

Section 504 Accommodations

Reasonable Accommodations Necessary for the Child to be Successful in the General Education Curriculum
Physical Environment

Cooling off period / All classrooms

Preferential Seating / All classrooms
Elevator access / All day
Extra time between classes / All classes

Calculator / Math and Science class

Large print / All classes
Graphic organizer / Writing class
Break worksheets into several sections / All classes

Instructional Materials

Instructional Methods

Checking for understanding / All classes

Repeated review / All classes
Assignments/Homework

Extended time to submit homework (1.5 times) / Science Class

Testing

small group / All classes

Oral administration / on allowable testing instruments
Behavior

Behavior modification plan with incentives / Math Class

Houston Independent School District

Test School
123 ABC St
Test, TX 55555
Phone: 123-456-7891 Fax: 112-345-1689
Student Name: Aaron Ben-Amram Test
Section 504 Student Service Plan

Student ID: TESTABAT

Section 504 Committee

Person Responsible for overseeing implementation of the 504 Service Plan:

Position
Parent:
Amram Test
Chairperson:
Mertie M Gomez

Signature

In Agreement
Yes

No

Yes

No

Date

Parent Confirmation

I certify that I am the parent or legal guardian of this child, have participated in the 504 meeting and development of
this service plan, and have received a copy of my Section 504 Notice of Parent and Student Rights and Procedural
Safeguards. I understand that when my child reaches the age of 18 all rights and procedural safeguards pursuant to
Section 504 will transfer to the student.
__________________________________

__________________________

Signature (Parent/Guardian or Adult Student)

Date

Documentation of Section 504 Review by Other Teachers not in Attendance

Signature

Date

Signature

Date

Signature

Date

Signature

Date

Signature

Date

Signature

Date