Attachment A - Individualized Section 504 Service Plan (Form S-25) Appendix Crosswalk (10.14.25)

ATTACHMENT A: Individualized Section 504 Service Plan (Form S-25) Appendix Crosswalk
aka Disability Diagnosis Report
This crosswalk shows which questions in the Appendix are follow-up questions for which sections of Form S-25.
Individualized Section 504 Service Plan (Form S-25)	Appendix Section	Appendix Question	Notes
Unaccompanied Alien Child's Information
Name
A#
	UAC Basic Information	What is the child's Portal ID number?	Follow-up question asking for an additional identifier associated with the child
Sex
Country of Birth
Birth Date
Age
Program Name
Program Type
Check if Out-of-Network (OON) Placement	UAC Basic Information	Is the child currently placed at an out-of-network facility? Yes No	Same question
OON Provider	UAC Basic Information	What is the name of the out-of-network facility where the child is currently placed?	Same question
	UAC Basic Information	In what type of out-of-network facilty is the child place? Acute medical care/rehabilitation facility Heightened Supervision Facility Therapeutic Group Home Residential Treatment Center (RTC) Secure Other	Follow-up question asking for more information about the OON facility placement
	UAC Basic Information	What date was the child placed at the out-of-network facility?	Follow-up question asking for more information about the OON facility placement
Details on Disability Diagnosis
Date 504 Plan Created
Date 504 Plan Last Updated
untitled table
Date Disability Identified
Disability/Diagnosis	Health Information	What physical or mental impairments have been diagnosed by a licensed mealth care provider that are affecting or may affect a major life activity for at least six (6) months?	Follow-up question asking for additional information about the disability/diagnosis
	Health Information	Please identify the credentials of the diagnosing healthcare provider.	Follow-up question asking for additional information about the disability/diagnosis
	Health Information	During which type of healthcare visit did the health care provider diagnose the first physical/mental impairment that is affecting/may affect a major life activity for at least six (6) months? Initial Medical Exam Medical visit (not IME) Mental health visit Required evaluation following a triggering event (please refer to the list of triggering events in UAC Policy Guide Section 3.8.3) Other	Follow-up question asking for additional information about the disability/diagnosis
	Health Information	If you selected "identified subsequent to a triggering event" for the previous question, what type of triggering event first identified the child's physical/mental impairment that is affecting/may affect a major life activity for at least six (6) months? The child was hospitalized for a psychiatric-related reason The child was being considered for hospitalization for a psychiatric-related reason The child is under consideration for placment or transfer to an RTC or similar restrictive therapeutic facility The child is under consideration for placment in a secure facility Child was recommended for an evaluation by a treating licensed medical or mental health professional Direct request of teh child or through the child's parent or legal guardian, or through their attorney and/or child advocate	Follow-up question asking for additional information about the disability/diagnosis
	Health Information	When was the child first diagnosed by a healthcare provider with a physical/mental impairment that is affecting/may affect a major life activity for at least six (6) months?	Follow-up question asking for additional information about the disability/diagnosis
	Health Information	How did the care provider first learn that the child has, or has had, challenges performing major life activities (select one). Reported by the child's healthcare provider Reported by the child By verbal or written report from the child's parent/legal guardian or sponsor Through review of a child's health records by the care provider program staff Observed by care provider program staff/foster parents Other	Follow-up question asking for additional information about the disability/diagnosis
Related Triggers, Behaviors, and Symptoms
504 Service Plan Team
untitled table
Name	Responder Information	What is your name?
Role	Responder Information	What is your job title or role at your program?
Contact Information
Accomodations and/or Services
Service Plan table
Area of Need/Specific Disability-Related Trigger
Accommodation or Service
Person Responsible for Implementing
Frequency of Accommodation or Service
Date of Implementation
Does this Service Plan incorporate all recommendations provided by the individual(s) who conducted the child's evaluation(s) for disability, if applicable? [yes/no]
Notes table
Date
Note
Discharge Planning
Sponsor Name
Sponsor Category
Home Study Updates table
Date
Note
Post-Release Services Planning Updates table
Area of Need/Specific Disability-Related Trigger
Post-Release Service or Support
Assistance Provided to Sponsor
Date Assistance Provided