Section 504: Eligibility Determination
Date of Meeting:
Eligible Eligible, but no accommodations or related services needed
Not Eligible
Student: Student ID:
Date of Birth: School: Grade:
Parent/Guardian: Home Phone:
Address: City: State: Zip:
Father’s Work Phone: Mother’s Work Phone:
Student Address: City: State: Zip:
Primary Language/Mode of Communication of Student:
Other Languages:
Primary Language/Mode of Communication in the Home:
Other Languages:
PARTICIPANTS IN MEETING
NameTitleInitial Attendance
______
______
______
______
______
______
Parent/Guardian Signature: ______
Student (as appropriate): ______
Individual providing the parent/guardian with the procedural safeguards Section 504 Parent/Student Rights in Identification, Evaluation and Placement ______
.
DATA REVIEWED:
Parent Information Student Work Samples Speech/Language Evaluation
Teacher Information Standardized Test Results Special Education Evaluation
Medical Information Discipline Record Psychological Evaluation
Attendance Records Classroom Accommodations Report Cards
Private Evaluation Social Work Report Observations
Behavior Assessment/Behavior Plan Information relating to current home/community behavior
Prior Section 504 Student Service Plan – Date of Plan:
Other – Specify
Note: A copy of the data considered at the meeting must be maintained in the student’s cumulative file.
Section 504: Eligibility Determination
Student: Student ID: Date of Birth: Grade:
1. Does the student have a mental or physical impairment? Yes No
Describe the impairment in detail:
2. Does the impairment substantially limit one or more major life activities (including major bodily function)? Yes No
If yes, check all that apply:
Major life activities include, but not limited to:
Caring for oneself Performing Manual Tasks Walking Seeing
Breathing Hearing Speaking Working
Learning Standing Reading Lifting
Concentrating Bending Communicating Thinking
Other:
Major bodily functions include, but are not limited to:
Immune System Digestive System Brain Function
Normal Cell Growth Bowel Function Bladder Function
Respiratory Function Circulatory Function Endocrine Function
Other:
3. Describe in detail how the mental or physical impairment is substantially limiting?
Section 504: Eligibility Determination
Student: Student ID: Date of Birth: Grade:
4. If the team’s determination is that the student has an impairment that substantially limits a major life activity, the student has a disability under Section 504.
Thus, is is not a qualified student with a disability under Section 504.
If the student has a disability, the team must determine if a Section 504 Accommodation Plan needs to be developed.
5. Because of the disability, the student is unable to receive the school’s services as adequately as non-disabled peers. Yes No
6. Because of the disability, the student requires a service or accommodation that is not available to all students. Yes No
If the team answered yes to either statement #5 or #6, then a 504 Accommodation Plan must be developed.
*Record eligibility and specific accommodations to be provided in Infinite Campus under the custom 504 tabs. Print out the Accommodation Plan report for distribution as listed below.
*Distribution:Student’s Cumulative File
Parent/Guardian
Principal
School Section 504 Coordinator
District Section 504 Coordinator
Page 1 of 3August 2012