SOUTH LANE SCHOOL DISTRICT

Section 504 Student Eligibility Form

Child’s Name: / Birthdate: / Date:

Eligibility Team Members: Fill in names and check areas of knowledge for each team members:

Name / Knowledgeable about child / Knowledgeable about evaluation data / Knowledgeable about accommodations/
placement options
Note: Make sure there is at least one check in each column

Sources of evaluation information (check each one used):

______achievement tests______file review

______cognitive assessments______teacher recommendations

______student work samples______medical report

______adaptive behavior______others(specify):

1.Specify the mental or physical impairment:

2.Check the major lifeactivity: ____seeing ____hearing ____walking ____learning

____reading ____thinking ____concentrating ____sleeping

____bowel functions ____bladder functions ____digestive functions____eating

____caring for oneself____performing manual tasks

or specify alternative of equivalent scope and importance: ______

3.Place an "X' on the following scale to indicate the specific degree that the impairment (in #1) limits the major life activity (in #2):

• Make an educated estimate without the effects of mitigating measures, such as medication; low-vision devices (except eyeglasses or contact lenses); hearing aids and cochlear implants; mobility devices, prosthetics, assistive technology; learned behavioral or adaptive neurological modifications; and reasonable accommodations or auxiliary aids/services.

•Similarly, for impairments that are episodic or in remission, make the determination for the time they are active.

•Use the average student of approximately the same age in the general (i.e., national) population as the frame of reference.

• Fill in specific information evaluated by the team that justifies the rating:

Impact of Function on Major Life Activities
Ineligible for 504 / Eligible for 504
Major Life Activity / 0
None / 1
Negligible / 2
Mild / 3
Moderate / 4
Substantial / 5
Extreme
Learning
Thinking
Concentrating
Other:

4. Team Decision

Note:Sections one (1), two (2), and three (3) must be answered in the affirmative in order for the student to be found

eligible.

☐ The student does not meet 504 eligibility requirements.

-OR-

☐ The student meets 504 eligibility requirements. The student currently requires specific accommodations thatare necessary in order to have an opportunity commensurate with nondisabled students (of the same age).

-OR-

☐ The student meets 504 eligibility requirements. The student does not currently require specific accommodations

because the impairment is episodic and not currently active or because the effect of the impairment is mitigated by external measures and the district’s medication policy addresses the situation.

Signatures of Team Members / Title / Agree / Disagree
☐ / ☐
☐ / ☐
☐ / ☐
☐ / ☐
☐ / ☐
☐ / ☐

Attachments:Medical reports and/or Health records

Teacher comments, , 504 screening form, observations, rating scales, test results, referrals

Reports of psychological evaluations

Notes of eligibility meeting

Other information

Distribution:Student 504 Folder

District Office

Parent (including a copy of Section 504 Parent/Student Rights)