Fillable FORM A: SECTION 504 REFERRAL Section 504 of (Irvine Unified School District)

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FORM A: SECTION 504 REFERRAL Section 504 of (Irvine Unified School District)

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©AEM/AALRR FORM A Pg 1 of 2
FORM A
SECTION 504 REFERRAL
Section 504 of the Rehabilitation Act of 1973 prohibits discrimination on the basis of
disability in any program or activity receiving Federal financial assistance. If you feel a
student may have a physical or mental impairment that substantially limits a major life
activity, please complete and return this form to your school site Section 504 Coordinator.
Student's Name________________________________________________________ Date________________
School__________________________________________Grade________________ DOB________________
Referring Party:
Parent Teacher School Nurse School Psychologist Administrator Other_______________
Describe why you are referring this student for a Section 504 evaluation:___________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Identified Mental or Physical Impairment(s) or Suspected Impairment(s):________________________________
Major Life Activities Possibly Impacted:__________________________________________________________
Medical Information: (A formal medical diagnosis is not required for Section 504 referral or eligibility.)
Does the student have any formal medical diagnoses? Yes No
If yes: Diagnosis:____________________Diagnosed by:_______________________ Date:___________
Diagnosis:____________________Diagnosed by:_______________________ Date:___________
Is the student on any medications? Yes (list)__________________________________________ No
If yes, what is the positive or negative impact of those medications on the student?_______________________
_________________________________________________________________________________________
Does the student utilize any other mitigating measures other than medication (e.g. behavior contracts, health plans,
learned/adaptive behaviors, assistive technology, etc.) that positively impact the student in school? If yes, please list
and describe the impact of each mitigating measure.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Copyright Protections Strictly Enforced
©AEM/AALRR FORM A Pg 2 of 2
Other Factors:
Describe any cultural, economic, or environmental factors that may have impacted this student: ____________
_________________________________________________________________________________________
_________________________________________________________________________________________
****Please attach any and all supporting documentation (medical records, letters, evaluations, etc.)
_________________________________________________________________________________________
Referring Party Name Signature Date
For School Site Section 504 Coordinator Completion Only:
Date Referral Received:
District Action:
IDEA Disability Suspected—Refer to Special Education Department and Send Notice
of Action
504 Disability Suspected—Convene Team to Conduct Review of Existing Data
No Disability Suspected---Send Notice of Action and Consider Recommending General
Education Interventions
Copyright Protections Strictly Enforced
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FORM A: SECTION 504 REFERRAL Section 504 of (Irvine Unified School District)

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Completed 11 February 2021

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