SECTION 504 CONFERENCE

COMMITTEE REPORT

School:

ロ Initial Conference / ロ Review / ロ Re-Eval Conference / Conference Date:
  1. Personal Information

Student Name: / Birthdate:
Sex: / Grade:
Ethnic Background: / Parent Name:
Address:
City: / State: / Zip:
Phone (Home) / (Work) / (Emergency)
  1. Conference Deliberation

a. The following data was presented: / ロ Discipline / ロ Test Scores / ロ Attendance
ロ Medical Information / ロ Grades / ロ Teacher Reports
b. Does the Committee have sufficient data to consider the determination of disability? / ロ Yes ロ No / Specify:
c. Is there physical or mental impairment? / ロ Yes ロ No / Specify:
d. Is there a history of impairment? / ロ Yes ロ No / Specify:
e. Is the student regarded as having an impairment? / ロ Yes ロ No / Specify:

FYI -- The following scale will be used by the Section 504 Plan Team to indicate the specific degree that the impairment (in #1) limits the major life activity of LEARNING.

For Your Information: The team will use your information and the following criteria to determine eligibility.

For an “X” at 4.0 or above, fill in specific information evaluated by the team that justifies the rating:

5 /
Extremely
/ ●Make sure the team focuses on the major life activity as a whole (e.g., learning), not in a particular class (e.g., math) or for a particular sub-area (e.g., socialization).
●Discount from the analysis sub-par performance due to other factors, such as normal moods, lack of motivation, and the immediate situation or environment. Similarly, make an educated estimate with the mitigation of medication.
●Use the average student in the general population as the frame of reference for purpose of comparison.
4 /
Substantially
3 /
Moderately
2 /
Mildly
1 /
Negligibly

SECTION 504 CONFERENCE

COMMITTEE REPORT

(continued)

Student: / Birthdate:
  1. Recommendations

On the basis of the data presented, the following decision was made:

ロStudent is not disabled. / ロStudent is disabled and qualifies for Section 504 services (refer to “Alternative Learning Plan”).
  1. Conference Participation

Parent(s)/Guardian(s):

ロ / I have been given the opportunity to participate in the Section 504 deliberations and understand the contents and reasons for the program recommended.
ロ / I have been informed verbally and in writing of my rights and options under Section 504 by
Staff: / Date:
ロ / Permission for the program to begin is: ロ Granted ロ Denied
Parent/Guardian Signature / Date
Administrator Signature / Guidance Counselor Signature
General Class Teacher Signature / Health Services Provider Signature
General Class Teacher Signature / Other Signature

CC:Parents/GuardiansTeacherPrincipal

Section 504 CoordinatorEducational Record

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