504 Eligibility Determination
NOTE: If a student undergoing Section 504 eligibility determination is deemed eligible for services pursuant to Section 504, the student is entitled due process protections, including manifestation determinations, regardless of whether the student is provided with any services under Section 504.
(For Section 504 eligibility, a student’s physical or mental impairment must substantially limit one or more major life activities.)
Student Name: ___________________________
DOB: _____________________
Date of 504 Eligibility Meeting:________
School: ___________
Grade: ________
Section 504 Evaluation (check one):
Initial Evaluation Reevaluation
1) Identify the referral issues or concerns noted by the parent and student, and/or staff: _____________________________________________________________ _________________________________________________________
2) The Section 504 Team has reviewed and considered the following information: (check all that apply)
Psychological/Psycho-Ed Evaluation* Teacher/administrator input
Grade Reports Medical Report
Parent Input Disciplinary Record
School Social Work Assessment Student Work/Anecdotal Records
Attendance Record OT/PT/SL Screening/Evaluation
Standardized Test Data Academic/Behavioral Interventions
School Health Information Health Plan (Attach Plan) Environmental/Cultural/Economic Factors**
*Required, if physical or mental impairment impacts learning. **Conditions resulting from these factors are not necessarilydisabilities.
3) Specify the student’s physical or mental impairment: ___________________________________________________________
(A physical impairment is any physiological disorder or condition, cosmetic disfigurement, or anatomical loss affecting one or more of the body systems. A mental impairment is any mental or psychological disorder. Physical or mental impairments are to be diagnosed by professional persons holding state license or certified through the Department of Education)
4) Is the impairment temporary (with a finite actual or expected duration): Yes No
If yes, explain (and indicate actual or expected duration): _____________________________________________________________ ________________________________________________________
(A temporary impairment does not constitute a disability for purposes of Section 504 unless its severity is such that it results in a substantial limitation of one or more major life activities for an extended period of time. Note that an individual is not “regarded as” an individual with a disability if the impairment is transitory and minor. A transitory impairment is an impairment with an actual or expected duration of 6 months or less.)
5) Does the student's documented physical or mental impairment impact the student in one or more of the following major life activities? No Yes
Caring for self
Performing manual tasks
Walking
Hearing
Seeing
Speaking
Breathing
Learning
Working
Eating \
Sleeping \
Lifting
Bending
Reading
Concentrating
Thinking
Communicating
Operation of major bodily functions Other: ____________
If seeing is indicated above, is the condition mitigated by ordinary eyeglasses or contact lenses? No Yes
(If yes, the student may not be eligible for services under Section 504.)
6) Does the physical or mental impairment substantially limit a major life activity? Yes No
A student is substantially limited when he or she is significantly limited as to the condition, manner, or duration under which he or she can perform a particular major life activity as compared to the cond duration under which the average student in the general population can perform that same major life activity.
7) Describe the impact, if any, that the physical or mental impairment has on a major life activity (without regard to any mitigating measures, i.e. medication): __________________________________________________________________ __________________________________________________________________ ____________________________________________________________
(If the impairment is episodic or in remission, describe the impact that the impairment has on a major life activity as if the episode is occurring or the illness is in full force)
8) The Section 504 Team has reviewed all available information and concludes the following:
The student’s disability does not substantially limit a major life activity.
The student does not meet Section 504 eligibility criteria.
The student’s disability substantially limits a major life activity. The student meets Section 504 eligibility criteria.**
Reevaluation complete. The student’s disability no longer substantially limits a major life activity. The student meets Section 504 dismissal criteria.
Reevaluation complete. The student’s disability continues to substantially limit a major life activity. The student continues to meet Section 504 eligibility criteria.**
Continue present services with no changes.
Modify the present program (see attached addendum or new plan)
If eligibility criteria are met for Section 504, complete Section 504 Plan.
If eligibility criteria for Section 504 are not met, identify any regular education interventions and strategies that may assist the student: __________________________________________________________________ __________________________________________________________________ ____________________________________________________________ **
If the student is deemed eligible under Section 504, the student is entitled due process protections, including manifestation determinations, regardless of whether the student is provided with any services under a Section 504 plan. The following persons, as indicated by their signatures, have participated in the Eligibility Determination:
Parent and student, as appropriate, have been provided with a copy of Section 504 Eligibility Determination and Parent/Student Rights.
__________________________________________________ Parent/Student Signature [or] Date copies provided via U.S. Mail Position Signature Date Do you agree with this determination? Parent Parent Student Administrator/Designee Regular Ed. Teacher Regular Ed. Teacher Special Ed. Teacher School Psychologist Counselor Other:_____ Other:_____
