Part III: Section 504 Eligibility Determination

1. Does the student have a physical or mental impairment(s)? Yes No

Specify the mental or physical impairment(s):______

*An Individual Health Plan (IHP) MUST be filled out by the nurse and attach Physician’s documentation of the medical disability.

2. What major life activity(ies) is/are affected by this condition and to what degree?

Place an “x” in the appropriate space to indicate the specific degree that the impairment limits the major life activity:

-Committee focuses and emphasizes the major life activity as a whole (e.g., learning) not a particular class (e.g. geometry).

-Discount from the analysis sub-par performance due to other factors such as normal moods, lack of motivation and the immediate situation or environment.

-Use the average student in the general population as the frame of reference for the purpose of comparison.

Life Activities Mildly Moderately Substantially Extensively

Self-Care
Walking
Seeing
Breathing
Learning
Working
Speaking
Concentrating
Bladder/bowel functions
hearing
Other:

*The impairment(s) must substantially/extensively limit the indicated major life activity to meet Section 504 eligibility requirements.

3. If the team’s determination is that the impairment does not substantially or extensively limit a major life activity, provide notice to the parents of their procedural rights, including an impartial hearing. If the team’s determination was the impairment does substantially/extensively limit a major life activity, the team should develop the 504/ADA Plan and indicate the specific accommodations that are necessary for the child to have an opportunity commensurate with non-disabled students (of the same age).

Note: If the student’s needs are so extensive that even with accommodations listed on the IAP the student’s needs cannot be adequately met in the general education setting, a referral to special education be considered.

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Part IV: Section 504 Committee’s Decision

The Section 504 Committee’s analysis of the eligibility criteria as applied to the evaluation data indicates that at this time: (check only one)

INITIAL EVALUATION
The student is not eligible for services under Section 504.
Student has a physical or mental impairment which substantially limits one or more major life activities. Regular classroom accommodations will be identified on an Individual Accommodation Plan (IAP).
Student is eligible under section 504; however, needs no accommodations at this time. An IAP is completed, signed by the committee and reviewed annually.
RE-EVALUATION
Student continues to be eligible under Section 504 and will receive an updated IAP according to the reevaluation
Student continues to be eligible under section 504; however, needs no accommodations at this time. An IAP is completed, signed by committee and reviewed annually.
Student is no longer eligible under Section 504 according to the reevaluation. An annual review is no longer needed. The student may be reconsidered for eligibility at any time through the SBLC process.

We certify that this report represents the best, integrated description of this student at this time. The evaluation meets the criteria for eligibility and required evaluation procedures for the disabling condition(s) listed above. It was determined that the following factors did not interfere with the reliability of the evaluation data for the total evaluation process: evaluation conditions, rapport, motivation, length of examination, communication, race, or sex.

Signatures of SATeam/504 Team Members participating in the Section 504 Disability Evaluation*

______**

Section 504 Chairperson Referring Teacher Parent (received Rights & Grievance Procedures)

______

Principal/Designee Additional Person Knowledgeable Additional Person Knowledgeable

of Student and/or Disability of Student and/or Disability

*The Section 504 Committee must consist of a minimum of three members knowledgeable of the student and/or the disability.

**If the parent is not in attendance, then Form 2c must be signed by the parent.

Copy to parent, 504 district office, original in student’s 504 folder

Deondra Warner, Section 504 Coordinator Tangipahoa Parish School System –Revised- August 2015

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(If Applicable)

Characteristics of Dyslexia- If student is consistently struggling or having difficulty making expected progress in areas of reading and/or written language.

NOTE: Reevaluation does not require re-screening assessment if completed in the past three years.

a. SBLC suspects Characteristics of Dyslexia Date______

b. Dyslexia Assessment (Screening Specialist-within past three years)

Dyslexia Assessment Report Results Indicate: _____Yes _____No, Characteristics of Dyslexia, and/or Date______

c. Pupil Appraisal Evaluation (attach copy)

Results Indicate: _____Yes _____No, Characteristics of Dyslexia, and/or Date______

d. Medical/Psychological Evaluation (attach copy-within past three years)

Results Indicate: _____Yes _____No, Characteristics of Dyslexia Date_____

List recommendations on evaluation report:

  • ______
  • ______
  • ______
  • ______
  1. Student demonstrates strength in some academic area(s). ______Yes, Academic Area______/ ______No
  1. For Reevaluation: Complete 1st page of assessment with current data. List any major changes in student achievement in comment section below. If a Medical/Psychological Evaluation was completed within the past 3 years, review the results. If student does not continue to meet Section504 Criteria, state reasons and dismiss on Eligibility page.

Note: If data indicates that current classification may not be appropriate, consider SBLC referral.

  1. Parent Meeting
  • 504 committee and parent review the results. Copy is given to parent or copy is mailed. Date______

COMMENTS: ______
______
______

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