Section 504 Eligibility Determination Form

Section 504 Eligibility Determination Form

Section 504 Eligibility Determination Form

Student Name:
ID #:
Parent Guardian:
Home Phone:
Work Phone:
Referred by:
Date of Referral:
Date of Meeting:
TheSAT/Section 504 committee reviewed and carefully considered the following data from the following sources: (Please check all that apply) / X / Explanation
Disciplinary Records/Referrals
Standardized Tests/Other Tests
Ancillary/Teacher/Administrator input
Student data folder
School Health Information
Medical Evaluations/Diagnosis
Parent Input
Academic Improvement Plan
Cumulative Folder
Parent Input Form (504 Form PI)
Based on the evaluation data discussed from the above checked resources, the Section 504 committee answered the following questions to determine Section 504 eligibility: / Y / N / Explanation
1.The students has: Neurological condition Physical Impairment Mental impairment
NOTE: This is an educational determination only, and not a medical diagnosis for purposes of treatment:
2. Does the physical or mental disability affect one or more major life activities? If, so, which major life activity or activities is/are affected?
3. Does the physical or mental disability substantially limit a major life activity?
4. Does the student need Section 504 accommodations in order for his/her educational need to be met to match those of the student’s non-disabled peers?
If all four questions were answered “Yes,” the student is eligible for a free appropriate public education under Section 504, and the Section 504 Accommodation Plan should be developed. If the answer is “No,” the student is not eligible.
The Section 504 committee’s determination for eligibility criteria as applied to the evaluation data indicates that:
(Please check only one)
The student is not identified for services under Section 504 and will continue to receive general education services, resources and programs.
The student is identified under Section 504 and will receive an Accommodation Plan, which will provide the provisions of Section 504 to the student.
The student remains identified under Section 504 and will receive an updated Accommodation Plan which governs the provision of Section 504 services to the student. (Annual and 3-year evaluations only)
The student is no longeridentified for Section 504 and is exited from the program. The student will now receive general education without Section 504 services. Refer to SAT to monitor.
Position / Printed Names / Signatures / Agree / Disagree
Person knowledgeable of the child
Person knowledgeable of the evaluation results
Person knowledgeable of placement options

If you disagree with Section 504 committee decision, please contact the Las Cruces Public Coordinator of Elementary Instruction for assistance.

Coordinator of Elementary Instruction: Lydia Polanco

Phone: 527-6011


504 Form EDF