Section 504

Eligibility Determination Summary

Student Name: ID#: DOB:

School: Grade:

Student Address:

City: State: Zip:

Parent(s) / Guardian(s):

Home Phone:

Date of Meeting / Completed Evaluation:

Purpose:

Initial Identification Triennial or Periodic Review Student Transfer

Teacher:

Section 504 Case Manager:

This form serves as documentation of the Section 504 Committee’s eligibility determination subsequent to an initial or periodic review.

Documentation of Procedural Safeguards

A copy of "Rights and Procedural Safeguards: Section 504 / ADA" was provided to parent(s)/guardian(s) on: by: (Staff Member name and position)

The following was reviewed by the Section 504 Committee in the evaluation of eligibility for this student:

Data / Source of Data
Educational Records
District Assessments
State Assessments
Mitigating Measures
Parental Information
Teacher Information
Discipline Records
Physician Reports
Other:
Other:

Comments / Additional Information:

Student Name: ID#: DOB:

Date of Meeting / Completed Evaluation:

Based on a review of all information, the Section 504 committee must answer the following:

1.)Section 504 defines a physical or mental impairment as "any physiological disorder or condition, cosmetic disfigurement, or anatomical loss affecting one or more body systems".

The student has a mental of physical impairment. No Yes

Disability(ies):

Comments/Additional Information:

2.)The mental or physical impairment affects one or more major life
activities, which may include a major bodily function. No Yes

If “YES”, indicate the major life activity(ies) that is/are limited by the mental or physical impairment:

Major Life Activities
(or Major Bodily Functions) / Data Source

Use the space below to provide a summary of items checked above and/orfor additional information:

3.)The mental or physical impairment identified above substantially
limitsa major life activity(ies)and/ora major bodily function(s): No Yes
Explain:
If the answer to question #3 is NO, indicating a determination that the mental or physical impairment identified in question #1 does not substantially limit either a major life activity or a major bodily function:

a.) Explain why the student is not substantially limited.

b.) Describe any mitigating measures that may be present and the positive impact of those measures.

Student Name: ID#: DOB:

Date of Meeting / Completed Evaluation:

Based on the review of all existing data and eligibility as detailed above, the Section 504 Committee concludes:

The student is eligible under Section 504:

The studentis eligible (or continues to be eligible in the case of periodic review) and will receive a Section 504 Services Plan developed by the Section 504 Committee. Student will receive manifestation determination, procedural safeguards, periodic re-evaluation or as needed, and nondiscrimination protections of Section 504.

The eligible studentdoes not require a Section 504 Services Plan. The identified impairment isin remission or there is no current need for services.Student will receive manifestation determination, procedural safeguards, periodic evaluation or as needed, and nondiscrimination protections of Section 504. If there isa need for the development of a Services Plan, the Section 504 Committee will reconvene to review thestudent's needs and develop an appropriate Section 504 Services Plan.

The eligible studentdoes not require a Section 504 Services Plan. The positive effect of identifiedmitigating measures are adequate when compared to his/her nondisabled peers.Student will receive manifestation determination, procedural safeguards, periodic evaluation or as needed, and nondiscrimination protections

The student is not eligible (or no longer eligible in the case of periodic review) for Section 504 services.
The Section 504 Committee has reviewed all current existing data, the student is no longer eligible for Section 504 Services, and will now receive regular education without Section 504 services. As a student with a record of an impairment, she/he will continue to receive nondiscrimination protections of Section 504 and procedural safeguards. She/he will not receive manifestation determination or periodic re-evaluation.

The following persons actively participated in this eligibility determination:

Signature / Printed Name
Person Knowledgeable of the Student
Title / Position
Title/Position
Title /Position
Parent
Other
Other

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