REQUEST FOR SECTION 504 EVALUATION
SAN FRANCISCO UNIFIED SCHOOL DISTRICT
STUDENT, FAMILY COMMUNITY SUPPORT DEPARTMENT
Date Request Submitted to School:
504 Evaluation Requested by: (Name & Relationship to Student—e.g. parent, teacher, etc.)
Student's Name Address Zip Code Telephone
Student ID # Date of Birth Primary Language Grade Level Parent/Guardian Name
School Name Name of School Site 504 Coordinator Three Digit School ID
1. Describe the nature of the suspected mental or physical impairment: (Definitions on reverse.)
2. State what major life activity that is thought to be substantially limited (can be more than one): (Definitions on reverse.)
3. Describe how the suspected impairment may substantially limit the above major life activity/-ies: (Definitions on reverse.)
4. List any current site accommodations and/or services that are in place:
5. Please attach COPIES of supporting documents, as applicable, in the following order:
SFUSD-Student, Family and Community Support Department Form 504-1
1. Documentation of Impairment Reports
(e.g. medical reports, psychological reports)
2. SST Summary Forms 2.0, 2.0a Records
(not required for physical impairment)
3. All Prior Assessment Reports
4. Attendance Records
5. Academic Progress
6. Current Grades & Scholarship
7. Test Scores
8. Other: ______
SFUSD-Student, Family and Community Support Department Form 504-1
School Administrator Signature (REQUIRED) DATEq I provided parent/guardian with a copy of the
Notice of Parent/Guardian/Student 504 Rights. / Parent Signature (REQUIRED) DATE
In signing above, I consent to my child being evaluated for Section 504 eligibility. I have been given a copy of my rights.
School Site: If consultation is needed from the Section 504 Resource Team, please send this completed and signed form, with copies of all supporting documents, to: District 504 Coordinator, SFCSD, School Health Programs, 1515 Quintara, SF, CA 94116.
For Use by District 504 Resource Team (for guidance to School Site 504 Coordinator, School Site SST/504 Team)
q School Site SST/504 Team is recommended to conduct 504 evaluation and, if appropriate, develop 504 Plan -or-
q AUGMENTED School Site SST/504 Team is recommended to conduct 504 evaluation and, if appropriate, develop 504 Plan.
If AUGMENTED School Site SST/504 Team is recommended, the personnel recommended to be added are:
______
______
______
SIGNATURE of District 504 Resource Team Member DATE PRINT Name of District 504 Resource Team Member
REQUEST FOR SECTION 504 EVALUATION
SAN FRANCISCO UNIFIED SCHOOL DISTRICT
STUDENT, FAMILY & COMMUNITY SUPPORT DEPARTMENT
Definitions under Section 504
The student must have a mental or physical impairment that substantially limits a major life activity.
Physical or Mental Impairment
A “physical or mental impairment” is defined as:
(A) Any physiological disorder or condition, cosmetic disfigurement, or anatomical loss affecting one or more of the following body systems: neurological; musculoskeletal; special sense organs; respiratory; including speech organs; cardiovascular; reproductive; digestive; genito-urinary; hemic and lymphatic; skin; and endocrine; or
(B) Any mental or psychological disorder, such as intellectual disability, organic brain syndrome, emotional or mental illness, and specific learning disabilities.
Additional examples, diseases, and conditions include: orthopedic; visual, speech and hearing impairments; cerebral palsy; epilepsy; muscular dystrophy; multiple sclerosis; cancer; heart disease; and diabetes.
The list of impairments is not intended as exhaustive of all diseases and conditions that may constitute a physical or mental impairment. A disease or condition not specifically listed may nonetheless constitute a physical or mental impairment under Section 504. Determinations must be made on an individualized case-by-case basis.
Major Life Activity
The second part of the definition relates to the impact of the disability or condition on a “major life activity.”
Section 504 defines a “major life activity” as: “…functions such as caring for one's self, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning and working.” Additional examples of major life activities include sleeping, standing, lifting, bending, reading, concentrating, thinking and communicating.
Major bodily functions are also considered major life activities such as the functions of the immune system, normal cell growth, digestive, bowel, bladder, neurological, brain, respiratory, circulatory, endocrine, and reproductive functions. The list is not exclusive and an activity or function not specifically listed can nonetheless be a major life activity.
Substantially Limits
Not all impairments affect an individual in a major life activity such that they are substantially impaired. An individual with a disability is someone who, due to an impairment, is substantially limited in performing a major life activity as compared to most people in the general population. An impairment need not prevent or severely restrict the individual from performing a major life activity to be considered a disability. While the limitation imposed be important, it need not rise to the level of severely or significantly restricting the ability to perform a major life function.
Determination of whether an individual is experiencing substantial limitation in performing a major life activity is a common sense assessment based on comparing an individual’s ability to perform a specific major life activity (which could include a major bodily function) with that of most people in the general population. The comparison between the individual and “most people” should be based on a common-sense approach that does not require an exacting or statistical analysis.
This is a summary. For further information, please see the Section 504 Resource Guide.
SFUSD-Student, Family and Community Support Department Form 504-1