Georgia is a 2nd-grade student who has been diagnosed by a physician with a severe

peanut allergy. Three times in the past two years, Georgia has been taken by
ambulance to the emergency room for being in close proximity to peanuts; she did not
eat them but had sat at a school lunch table where peanuts had been previously
present. Georgia is bright, earns Mastery on her report card in reading and math and
loves music. In 2nd grade, students are required to take a cooking course related to
Food Services in meeting Career-to-Work standards. Georgia is socially awkward and
expresses feelings of rejection from her peers as a result of her food allergy.

SECTION 504 PLAN

FOR STUDENTS WITH PEANUT AND/OR TREE-NUT ALLERGIES (PTAs)

Student Name: Georgia Walker

Birthdate: 3/05/09
Food Allergies: Severe Peanut Allergy
School: South Park Elementary Center
Grade: 2nd
Period Covered By Plan: 9/28/17 9/27/18
Initial Evaluation Date: 7/28/17 Re-Evaluation Due Date: 7/28/20

1. Is the student disabled as defined by Section 504 of the Rehabilitation Act of

1973?
Yes
2. Describe the nature of the disabling condition.
Doctors diagnosis of severe peanut allergy.
Symptoms: tingling of lips and mouth, flushed face or body, itchy eyes,
nose, face, diarrhea, wheezing, swelling, vomiting, hiving, fatigue
3. Does the disability substantially limit a major life activity? Which area?
Yes, Breathing

Accommodations
4. Ensure that all accommodations in this plan and Georgias Food Allergy
Emergency Plan are fully implemented, and modified where necessary.
5. Ensure that the school nurse or outside physician provide effective PTA
training for all individuals involved with Georgia during her school day,
including school faculty and staff, food service members, custodial staff, PCAs
or paraprofessionals. The training must include
Common causes of PTA reactions and emergencies
Recognizing symptoms of PTA reactions and emergencies
Properly responding to PTA reactions and emergencies
Administering PTA-related medication or EPI-Pen when applicable
A thorough review of the contents of this plan and Georgias Food
Allergy Emergency Plan
 Instruction on properly implementing this plan
A copy of both plans will be maintained in the classrooms where a
substitute may be
6. Ensure that all individuals and staff mentioned above have their own copies
of both plans
7. Ensure that at least one PTA-trained individual with authority to administer
PTA-related medication is present during Georgias school day, any after
school activities she is in, or outside but school-related activities
8. Ensure Georgias parents are immediately informed of any PTA related
reaction
9. Upon parent and nurse approval, develop an individual health care plan for
Georgia to carry around her own medication, including an EPI-pen
10. Ensure that in a potentially life-threatening PTA reaction situation, the
appropriate emergency response agency is notified
11. Ensure all parents of other students in the school are informed by letter, at
least twice per year, regarding the following topics:
A student in the school has a severe PTA
If exposed to PTA through contact or ingestion, the student may
develop a life-threatening PTA reaction that requires immediate
medical attention
Strict avoidance of PTA is the only way to prevent incidents
To reduce the risk of exposure to PTA, the classrooms and activities
(including field trips) will be PT-free
Students sharing a classroom with this student are not permitted to
eat PT in class or during shared activities
Students may bring PT to eat for lunch in the cafeteria
There will be a designated PT-free table for the student to sit at
12. Ensure that in the event of a PTA reaction while at school or in a school-
related activity, Georgia receives immediate care as per her Food Allergy
Emergency Plan and is administered the appropriate medication as needed
13. Copies of Georgias plans and medication list along with expiration dates are
readily available to staff
14. EPI-pens are kept in front office, cafeteria, related teachers classrooms, and
any other teachers Georgia sees
15. Students sharing a classroom with Georgia are prohibited from distributing
or consuming PT foods
16. Maintain a list of replacement snacks as provided by Georgias parents to
ensure she has food when needed in the classroom
17. Monitor food service activities including:
Ordering food products
Reading food ingredient labels
Planning menus
Selecting recipes
Establishing and monitoring food handling procedures
 Cleaning all PT-free cafeteria tables and chairs before and after each
meal shift ends

Signature: Title:

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