Name School Grade Teacher DX Parent Number Notes

Student 1 ZLE 4th Teacher A Anxiety Parent A 555-5555

**Initial Meeting is
Student 2 ZLE 4th Teacher B GAD Parent B 555-5555 November 30
**On Initial RtI
Student 3 ZLE 4th Teacher C ADHD Parent C 555-5555 November 28
Meeting 11/16/16:
Student 4 ZLE 4th Teacher D ADHD Parent D 555-5555 Mom bringing in dx
 504-4
Google 504-1 Permission to 45 DAY DUE
Vanderbilt Survey Safeguards 504-2 Referral 504-3 Pre-Eval Evaluate DATE
11/02/16 01/13/17 03/22/17
12/07/16
N/A 01/25/17 12/07/16 12/07/16 Does not Qualify 02/28/16

rec'd 11/28/16 11/28/16 11/28/16 2/16/17

Completed 504-5 Notice 504-6 Eval 504-7 Eligibility 504-8 Proposed 504-9 Change in
date of re-eval Report Determination EEOP placement
 desk config., check-in's, direct
Student Name School Grade Disability instruction, transition warnings.
Accommodations Start Date
quiet testing, movement breaks,
ADHD/Adj. w/dep.
Beddor, Ethan ZLE 4th ASD
mood, sensory
across multiple days 4/30/2015
task card, movement breaks,
Welters, Ray ZLE 3rd outside of school visual learning 5/22/2015
check hearing aids with nurse,
Gallager, Michael ZLE K DHH preferential seating 05-20-16
Review Date/End 504 Fidelity
Date Notes Checks
4/28/2017
6/9/2017
05-20-17