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Archdiocese of Kansas City in Kansas
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Catholic School Student Support Plan
Catholic School Student Support Plan - Form C136
CATHOLIC SCHOOL STUDENT SUPPORT PLAN in compliance with Section 504 requirements for private schools
Student's Name:
Date of Birth:
Age:
Grade:
School:
Meeting Date:
Parent's Name:
Phone:
Reasons for Referral:
Relevant Evaluation Results
1. Classroom Performance:
With Minor Adjustments
Without Minor Adjustments
Supporting Documentation/Information:
2. Academic Assessment Results:
With Minor Adjustments
Without Minor Adjustments
Supporting Documentation/Information:
3. Diagnosis:
Medical Professional/Clinic:
Date:
Additional Information:
DOCUMENTATION OF ELIGIBILITY FOR CATHOLIC SCHOOL STUDENT SUPPORT PLAN in compliance with Section 504 requirements for private schools
1. The student has:
Physical or mental disability which substantially limits one or more major life activities and requires minor adjustments in the classroom.
Physical or mental disability which does not substantially limit one or more major llfe activities and does not require minor adjustments in the classroom.
2. Basis for making the determination of disability:
CATHOLIC SCHOOL STUDENT SUPPORT PLAN in compliance with Section 504 requirements for private schools
1. AREA OF NEED: Adaptations for Instruction Minor Adjustments (Check all that apply)
Additional Guided Practice
Strategy Instruction
Frequent Feedback during Instruction
Key Concepts Emphasized
Preface Directions
Repeat Directions
Have Student Repeat Directions Orally
Group Similar Items/Problems
Use Visual Study Aids (graphic organizers)
Use Auditory Aids (cues, tapes)
Assistive Technology (computers, calculator)
Small Group Instruction
Direct Instruction
Peer Note Taking
Peer Tutoring
Extra Time for Oral Responses
Extra Time for Written Responses
Other
Other
Other
Other
Other
Other
Other
Other
Other
Other
Other
Other
Other
Other
2. AREA OF NEED: Assignments Minor Adjustments (Check all that apply)
Reduce quantity of work
Extra Time to Complete Assignment
Oral Assignments
Alter Spelling Words
Reduce Essay Work
Other
Other
Other
Other
Other
Other
Other
Other
Other
Other
Other
Other
Other
Other
3. AREA OF NEED: Assessments Minor Adjustments (Check all that apply)
Provide detailed study guide
Exams reduced in length
Quizzes reduced in length
Test Orally
Read Test Items to Student
Recorded Responses
Open Book/Open Note Test
Allow Additional Time for Testing
Allow Student to Test in Alternate Location
Provide Vocabulary List
Reduce or No Essay Questions
Use General Items for Testing
Give Take-Home Test
Other
Other
Other
Other
Other
Other
Other
Other
Other
Other
Other
Other
Other
Other
4. AREA OF NEED: Behavior Management Minor Adjustments (Check all that apply)
Clearly Defined Rules
Frequent Reminder of Rules
Verbal Cues to Stay on Task
Assignment Journal
Behavior Plan in Collaboration with Parents
Progress Chart
Behavior Management Plan
Private Counseling
Proximity Control
Preferential Seating
Frequent Breaks
Provide Opportunity for Movement
Provide Opportunity to Stand for Lessons
Ignore Behaviors
Supervise During Transitions
Time Out
Other
Other
Other
Other
Other
Other
Other
Other
Other
Other
Other
Other
Other
Other
Environment (See below):
Other
Other
Other
Other
Other
Other
Other
Other
Name of Person Submitting Form:
Email Address of Person Submitting Form:
Position of Person Submitting Form:
Date Submitting Form:
Submit
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