SECTION 504 ELIGIBILITY DETERMINATION FORM [Short Form]
A. Purpose of Meeting
Determine initial eligibility under Section 504 and consider eligibility for accommodations/related aids or services.
Review eligibility under Section 504
Review eligibility and accommodations/related aids or services before significant change in placement.
B. 504 Eligi
bility Team Members: (check the categories that apply to each team member below)
NAME/POSITION: KNOWLEDGEABLE ABOUT:
Child Meaning of Evaluation Data Accommodations/Placement Options
Child Meaning of E
valuation Data Accommodations/Placement Options
Child Meaning of E
valuation Data Accommodations/Placement Options
Child Meaning of E
valuation Data Accommodations/Placement Options
Child Meaning of E
valuation Data Accommodations/Placement Options
Child Meaning of E
valuation Data Accommodations/Placement Options
C. Sources o
f Evaluation InformationCheck those that apply:
Observations of Student
Teacher Reports
Checklists/Rating Scales
Functional Behavior Assessment (FBA) _____
Nursing Assessment
Parent/Student Interviews
School Records Review
Grades and Report Card Review _____
Parent and/or Student Report _____
Response to Intervention (RTI) _____
Medical/Health Information _____
Standardized Testing
Other:
D. Eligibi
lity Criteria:
1. The student has a mental or physical impairment (specify the nature of the impairment):
1
and
2. The impairment substantially limits one or more of the following major life activities (check all that apply):
seeing
walking
sleeping
reading
breathing
eating
bending
communicating
speaking
sitting
hearing
learning
standing
concentrating
performing manual tasks
reaching
caring for oneself
working
lifting
thinking
operation of a major bodily function
interacting with others
other:
The term
“substantially limits” means that the student is
(a) UNABLE to perform a major life activity that the average person in the general population can perform; or
1
The 504 Team does not itself diagnose the student
Student’s Name: DOB: Age:
School: Grade:
Parent(s)/Guardian(s):
Case Manager/Contact Person: Position: Date of Meeting:
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Ruth Wentzel - Special Education Director
(b) SUBSTANTIALLY RESTRICTED as to the condition, manner or duration under which a particular life
activity is performed
when compared to most students in the general population at that age or grade level (compared to national norms).
E. Eligibility Determination:
The student does NOT have a physical or mental impairment and/or any identified impairment does not
substantially limit a major life activity. Therefore, the student is NOT eligible for a Section 504 plan. The parent
must be provided with a copy of procedural safeguards.
The student DOES HAVE a physical or mental impairment that substantially limits a major life activity.
The student requires accommodations/related aids or services in a 504 plan.
The student does not require accommodations/related aids or services in a 504 plan at this time.
Recall that students with a past “record” of a disability may occasionally need an accommodation such as
time away from school for a check up on their former condition.
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