Kingsport City Schools

Section 504

Eligibility Determination

Referral

  1. Describe the nature of the concern.
  1. What is the mental or physical impairment?
  1. Describe how the impairment substantially limits the student’s ability to participate in or benefit from the educational program.

Eligibility Team Members: List and check area of knowledge. (Attach an additional page as needed for other members.)

NamePositionKnowledge Of

Child Evaluation Data Placement Options

______

______

______

______

______

______

This committee reviewed the following evaluation data: (Check all that apply.)

  • Grade Reports
  • Standardized test data (e.g., achievement, intelligence, behavioral)
  • Student Work Portfolio
  • Medical Evaluation/Diagnosis
  • School Health Information
  • Parent Input
  • Teacher/Administrator Input
  • Student Support Team Suggestions
  • Other ______

Based on the evaluation data gathered from a variety of sources the Section 504 Committee concludes:

  1. ___ The student does not exhibit a mental or physical impairment.

OR

___ The student does exhibit a mental or physical impairment. Specify impairment:

______

  1. ___ The impairment does notaffect a major life activity.

OR

___ The impairment does affect one or more major life activities. Specify major life activity

or activities affected:

___Seeing ___ Hearing ___ Speaking ___ Performing Manual Tasks ___Walking ___ Breathing ___ Learning ___ Other ______

  1. Please check the team decision on the specific degree* that the impairment (in #1) limits the major life activity (in #2):

* The team should focus on the major life activity as a whole (e.g., learning), not in a particular class (e.g., math) or for a particular sub-area (e.g., testing).

*The team should use the average or typical child of the same age/grade as the basis for comparison.

*The team should not consider mitigating measures.

___Substantially

___Moderately

___Mildly

  1. The student needs Section 504 services in order for his/her educational needs to be met as adequately as those of non-disabled peers.

___No

___Yes

(Note: If the student’s needs are so extreme as to require special education and related services, a referral to special education should be considered if this has not been previously done.)

The Section 504 team’s analysis of the eligibility criteria applied to the evaluation data indicates:

  • The student is not eligible for services under Section 504 and will continue to receive

regular education and any available regular education resources and programs.

  • The student is eligible under Section 504 and will receive an Individual AccommodationPlan to govern the provision of Section 504 services to the student.
  • (Annual and Re-Evaluation Only) The student remains eligible under Section 504 and

will receive an updated Individual Accommodation Plan to govern the provision of

Section 504 services to the student.

  • (Annual and Re-Evaluations Only) The student is no longer eligible for Section 504 and is exited from the program. The student will now receive regular education without

Section 504 services.

Section 504 Committee Signature

NameTitleDate

______

______

______

______

______

______

______

Section 504 Parental Rights were given and explained to parent(s)/Guardian(s):

_____ YesDate: ______

_____ No

Reevaluation Date: ______

**Comprehensive reevaluations must be conducted at least every three (3) years after the initial assessment**

Signature: ______Date: ______

(Parent/Guardian)

Signature: ______Date: ______

(Parent/Guardian)

Copies to:_____ Parent/Guardian

_____ School Section 504 File

_____ District Section 504 Coordinator