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8301 Professional Place, Landover, MD 20785 MODEL SECTION 504 PLAN FOR A STUDENT WITH EPILEPSY
[NOTE: This Model Section 504 Plan lists a broad range of services and
accommodations that might be needed by a student with epilepsy in the school setting
and on school-related trips. The plan must be individualized to meet the specific needs of
the particular child for whom the plan is being developed and should include only those
items that are relevant to the child. Some students may need additional services and
accommodations that have not been included in this Model Plan, and those services and
accommodations should be included by those who develop the plan. The plan should be
a comprehensive and complete document that includes all of the services and
accommodations needed by the student.]
Section 504 Plan for _____________________________
(Name of Student)
Student I.D. Number__________________
School___________________________________
School Year_______________
_________________ ________________ Epilepsy____
Birth Date Grade Disability
Homeroom Teacher_____________________ Bus Number________
OBJECTIVES/GOALS OF THIS PLAN:

Epilepsy, also referred to as a seizure disorder, is generally defined by a tendency for
recurrent seizures, unprovoked by any known cause such as hypoglycemia. A seizure is
an event in the brain which is characterized by excessive electrical discharges. Seizures
may cause a myriad of clinical changes. A few of the possibilities may include unusual
mental disturbances such as hallucinations, abnormal movements, such as rhythmic
jerking of limbs or the body, or loss of consciousness. In addition to abnormalities during
the seizure itself, individuals may have abnormal mental experiences immediately before
or after the seizure, or even in between seizures.
The goal of this Section 504 plan is to outline the special education and/or related
services and/or accommodations and/or aids necessary to maintain (Name of Student) at
school so that s/he may participate in and benefit from school services, programs, and
activities. These services and accommodations must be provided in accordance with this
plan and with the student’s seizure action plan, which is attached to this Section 504 Plan
and incorporated into it.
REFERENCES:
School accommodations, epilepsy care, and other services outlined in this plan will be
consistent with the prescriptions and other orders provided by (Name of Student’s)
physician, the attached seizure action plan and with the information and protocols
contained in The Epilepsy Foundation’s “Managing Students with Seizures: A Quick
Reference Guide for School Nurses” (2006).

DEFINITIONS OF TERMS USED IN THIS PLAN:
Absence seizures: Seizures (sometimes called petit mal seizures) that are usually just a
few seconds long. They happen suddenly and the person will stop what he or she is
doing, and then resume it as soon as the seizure is over. They may happen many times
in a day or in clusters during the day. Type of generalized seizure.
AED: Antiepileptic drug. Medication used to treat seizures. Common medications
include Dilantin, Keppra, Topamax, Depakote, Depakene, Lamictal, Zonegran, and
Clonapin, among others.
Atonic seizures: Also called drop seizures, these seizures produce a sudden loss in
muscle tone. A person’s head will drop or the person will drop to the ground. Injury can
occur; these seizures occur without warning. Type of generalized seizure.

Clonic seizure: Seizures in which a person’s arms and legs jerk rhythmically. Clonic
seizures by themselves are uncommon. Generalized seizure type.

Complex partial seizures: Seizures begin in one part of the brain and involve a loss of
consciousness or impaired consciousness. May cause automatic behaviors such as lip
smacking, chewing, swallowing, fidgeting, or other repetitious, stereotypic behavior.

Diastat Acudial: Rectal diazepam (class of drugs to which valium belongs). Diastat
Acudial is an effective means of aborting a lengthy seizure or a cluster of seizures and
was designed to avoid trips to the emergency room.
Generalized seizures: Seizures that affect both sides of the brain and produce loss of
consciousness for either a brief or longer period of time. Generalized seizures include
absence seizures, atonic or drop seizures, and tonic, clonic, myoclonic, and tonic-clonic
seizures.
Ketogenic diet: A special low-calorie, high-fat diet in which the body is placed in a state of
ketosis so that it burns fat for energy instead of carbohydrates. Ketosis has been effective
in providing seizure control or partial seizure control for many children.
(301) 459-3700 • (888) 886-EPILEPSY • FAX: (301) 577-2684 • postmaster@efa.org • Myoclonic seizures: Seizures in which the person experiences quick muscle contractions that usually occur on both sides of the body at the same time. They look like quick muscle jerks. Generalized seizure. Partial seizures: Seizures in which the electrical firings of the neurons are limited to a specific area of one side of the brain. Simple partial seizures: During these seizures a person remains aware of what is going on but may be limited in how he or she can react. The person may not be able to speak, or may experience tingling or pain, visual distortions, or other symptoms that may warn of more severe seizures to come. Seizure action plan: A plan that is designed to provide basic information about the student’s seizures and treatments. A completed plan should be provided to all relevant school personnel at the beginning of the school year, when a diagnosis of epilepsy is made or when a change in health status occurs. The plan should be signed and approved by the student’s treating physician. Status epilepticus: A period of prolonged seizure activity either because of one prolonged seizure or because of a series of seizures without the person returning to baseline. Current medical definitions consider 10 minutes as the amount of time after which uninterrupted seizure activity would be considered status epilepticus. It is possible that brain damage or death can result from status seizures. During status seizures, problems can arise if there is pulmonary or cardiac arrest that is not promptly treated. More often, however, serious negative consequences occur hours or days after the onset of status as a result of prolonged stress, oxygen deprivation and systemic complications such as organ failure. Tonic-clonic seizures: The most common type of seizure (sometimes called “grand mal” seizures). They begin with a tonic phase, in which the arms and legs stiffen, and then continue with a clonic phase, in which the limbs and face jerk. During the tonic portion of a seizure, a person may have an initial vocalization followed by their breathing slowing or stopping; during the clonic portion, breathing usually returns, but may be irregular, noisy or seem labored. The person may be incontinent and may bite his or her tongue or the inside of his or her mouth during the seizure. Generalized seizure. Tonic seizures: Seizures in which the person’s leg, arm, or body muscles stiffen. The person’s legs may extend. The person usually remains conscious. Generalized seizure. Vagus nerve stimulator (VNS): The VNS is similar to a pacemaker, but it stimulates the vagus nerve in the neck, instead of the heart. The VNS is usually implanted in the upper left chest or under the arm; it stimulates, on an ongoing basis, the vagus nerve, which then sends electrical impulses to the parts of the brain that affect seizures. If a person has a seizure aura or begins to have a seizure, the VNS can be swiped with a magnet to send additional electrical current to abort or minimize the seizure. (301) 459-3700 • (888) 886-EPILEPSY • FAX: (301) 577-2684 • postmaster@efa.org •
1. PROVISION OF EPILEPSY CARE

All staff members at the school shall receive general training regarding epilepsy and first aid for a person who is having a seizure. All staff members at the school who will be serving (student’s name) shall receive general training regarding the protocol to be followed if s/he has a seizure at school or a school-related event. Any staff member who has primary care for (student’s name) at any time during school hours, extracurricular activities, or during field trips or other school-related events or activities shall receive training that includes a general overview of epilepsy and the typical health care needs of a student with epilepsy, types of seizures and how to recognize each type, the type(s) of seizures (student’s name) has, what medication(s) the student takes and how and when to administer the medications if the staff member will be responsible for medication administration, and how and when to contact a school nurse if medication will be administered by the nurse or if (student’s name) health status warrants attention from the nurse. Any bus driver or other person who transports the student to and from school must be able to recognize and respond to a seizure if (student’s name) has a seizure while on the way to or from school or a school-related event. The following staff member(s) will be identified as the staff responsible for providing care to (student’s name) in the event of a seizure: _____________________________________________________ _____________________________________________________ _____________________________________________________ All students in (student’s name’s) class(es) and other students in the school, as deemed appropriate by school staff and (student’s name’s) parent/guardian, shall be educated about epilepsy in general and, as deemed appropriate by school staff and (student name’s) parent/guardian, about what to expect regarding (student name’s) seizures specifically.
2. STUDENT’S LEVEL OF SELF-CARE AND LOCATION OF SUPPLIES AND
EQUIPMENT

(Student’s name) is able to walk to the nurse’s office independently to take routine (301) 459-3700 • (888) 886-EPILEPSY • FAX: (301) 577-2684 • postmaster@efa.org • (Student’s name) needs assistance or supervision to take his or her routine medication. S/he needs assistance with the following care tasks: (a) ______________________________________ (b) ______________________________________ (c) ______________________________________ (d) ______________________________________ (Student’s name) needs a person to perform the following care tasks during a seizure: (a) ______________________________________ (b) ______________________________________ (c) _______________________________________ _________________________________________________ 3. EXERCISE, PHYSICAL ACTIVITY, AND REST PERIODS:
(Student’s name) shall be permitted to participate fully in physical education classes and team sports except as set out below in accord with physician orders: ______________________________________________ ______________________________________________ ______________________________________________ Physical education instructors and sports coaches must be able to recognize the student’s seizures and assist with first aid. Responsible school staff members will make sure that any needed emergency AEDs such as Diastat Acudial are available for (student’s name) at the site of his/her physical education class and team sports practices/games. School staff shall ensure that if (student’s name) has a seizure and needs to sleep or rest afterwards or otherwise needs to rest during the school day, he or she will have the opportunity to do so in a safe, supervised, comfortable setting. The setting does not have (301) 459-3700 • (888) 886-EPILEPSY • FAX: (301) 577-2684 • postmaster@efa.org • to be the school nurse’s office, and supervision does not have to be provided by the
school nurse, unless physician orders so require.
4. KETOGENIC DIET
4.1 (Student’s name) shall have access to needed food and liquids as required during the school day in order to maintain the protocol of the ketogenic diet. (Student’s name) parent/guardian shall provide pre-measured supplies of food and liquid to the school on a daily basis. 4.2 School staff who work with (student’s name) shall be trained regarding the ketogenic diet so that violations of the diet do not occur at school. 4.3 As appropriate, classmates of (student’s name) shall be given information about the ketogenic diet so that they do not share food with him/her. 4.4 As appropriate, during class parties or celebrations with food, alternatives shall be arranged for (student’s name) that enable him/her to partake in the celebration if s/he will be unable to eat or drink during the party time. Such alternatives may include, but are not limited to, playing a special role in the celebration, choosing music for the party, or being the “emcee.”
5. VAGUS NERVE STIMULATOR
5.1 School staff who work with (student’s name) shall be trained regarding the vagus nerve stimulator (VNS) and how it works. 5.2 A staff person shall be identified who shall be trained to swipe the magnet over the VNS in the event that (student’s name) has a seizure, as stated in the attached Seizure Action Plan. 5.3 A log shall be kept of each instance in which the VNS is swiped and the parents shall be notified at the end of each school day in which a swipe occurred.
6. ROUTINE ANTIEPILEPTIC DRUGS AND DIASTAT ACUDIAL
6.1 As stated in the attached Seizure Action Plan, (Student’s name) shall be given his/her prescribed doses of AEDs in accordance with physician orders. 6.2 School staff shall identify a person and a back-up person to be trained to administer Diastat Acudial or other appropriate emergency AEDs to (student’s name) in accordance with physician orders, as stated in the attached Seizure Action Plan. A trained staff member shall be available to perform this task all times during which (student’s name) is at school or attending a school-related activity or event. (301) 459-3700 • (888) 886-EPILEPSY • FAX: (301) 577-2684 • postmaster@efa.org • 7. FIELD TRIPS AND EXTRACURRICULAR ACTIVITIES
7.1 (Student’s name) will participate in all field trips, extracurricular activities, and school-related activities and events (such as sports, clubs, enrichment programs, and overnight trips) without restriction and with all of the accommodations and modifications, including necessary assistance and supervision by identified school or contract personnel, set out in this Plan. (Student’s name’s) parent/guardian will not be required to accompany him/her on field trips or any of these other listed events or activities. 7.2 A trained person shall be designated to be available on site at all field trips, extracurricular activities, and other school-related activities and events to provide administration of any necessary medication in the event of a seizure, or any other seizure first aid as needed. 7.3 The student’s AEDs will travel with the student to any field trip or extracurricular activity on or away from the school premises.
8. CLASSROOM WORK AND TESTS
8.1 If (student’s name) has a seizure during a test, he or she will be allowed to take the test at another time without any penalty. 8.2 If (student’s name) has side effects from AEDs that affect his/her ability to concentrate on schoolwork or tests, s/he may have extra time to complete assignments and tests without any penalty. 8.3 If (student’s name) arrives to school late because of an adjusted start time due to the need to wake up later to avoid morning seizures, s/he will not be penalized for work missed and will be given an opportunity to make up the work. 8.4 (Student’s name) shall be given instruction without penalty to help him/her make up any classroom instruction missed due to epilepsy care. 8.5 (Student’s name) shall not be penalized for absences required for medical appointments and/or for illness related to his/her epilepsy.
9.0 DAILY INSTRUCTIONS AND COMMUNICATION
9.1 Every substitute teacher and substitute school nurse shall be provided with written instructions regarding (student’s name) seizure care and a list of all school nurses and staff involved in his/her care at the school. 9.2 (Student’s name’s) parents shall be informed each day of any seizures that occurred at school or at any school-related activity or event. The information given to the parents shall be in writing and shall include information about the (301) 459-3700 • (888) 886-EPILEPSY • FAX: (301) 577-2684 • postmaster@efa.org • type(s) of seizures that occurred, any first aid or other treatment provided, and any other relevant information. 9.3 As stated in the attached Seizure Action Plan, in the event of an emergency such as a seizure that results in an unusual response, school staff shall contact 911 and notify (student’s name’s) parents.
10. EMERGENCY EVACUATION AND SHELTER-IN-PLACE

10.1 In the event of an emergency evacuation or shelter-in-place situation, (student’s name’s) Section 504 Plan shall remain in full force and effect. 10.2 The school nurse or other person identified by school staff and named in this Plan, shall provide seizure care as outlined in this Plan and will be responsible for transporting (student’s name’s) medication. He or she shall remain in contact with (student’s name’s) parents/guardians, and shall receive information, guidance, and necessary orders from the parents regarding seizure care.
11. EMERGENCY CONTACTS:
___________________ ______________ ____________ _________
Parent/Guardian Name Home Phone Work Phone Cell Phone
__________________ _______________ _____________ _________
Parent/Guardian Name Home Phone Work Phone Cell Phone
Other Emergency Contacts:
____________________ ____________________ ____________________
Name Home Phone Work Phone
____________________ ____________________ ____________________
Name Home Phone Work Phone
Physician(s):
___________________ ______________________
Name Phone
___________________ ______________________
Name Phone
(301) 459-3700 • (888) 886-EPILEPSY • FAX: (301) 577-2684 • postmaster@efa.org •

Source: http://edmedkids.arizona.edu/sites/default/files/EF%20504%20Plan%20Sample%20B%20-%20Eplilepsy.pdf

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