PRAIRIE-HILLS ELEMENTARY SCHOOL DISTRICT NO. 144
SECTION 504 Eligibility Determination
General Information:
Student: ______Meeting Date: ______
Address: ______Phone: ______
______School: ______
Grade:____ Teacher:______Case Manager: ______
Purpose of Conference:
o To consider possible eligibility under Section 504 of the Rehabilitation Act of 1973 and the need for services and/or accommodations.
o To review eligibility under Section 504 of the Rehabilitation Act of 1973 and the need for services and/or accommodations.
oOther (Specify)______
Conference Participants:
______
Parent/Guardian Other (specify)
______
Parent/Guardian Other (specify)
______
LEA Representative Other (specify)
______
General Education Teacher Other (specify)
______
Other (specify) Other (specify)
______
Other (specify) Other (specify)
oParent(s)/Guardian(s) received a copy of the Section 504 “Parents Rights in Brief”
Parental Consent to Evaluate:
______
Signature Date
Evaluation DATA:
The team reviewed and carefully considered the following data gathered from a variety of sources. (Please check all that apply.)
oCurrent Classroom Functioning oParent, Teacher and/or Student Interview
oEducational History oHealth Record, History, and/or Update
oDiscipline Record oAssessment of Social/Emotional Functioning or History
oAttendance Record oParent Input
oLocal and State Wide Assessments oReports from Other Sources
oPrior Special Education Evaluations oOther ______
oClassroom Observations oOther ______
If information from a conversation or other data in unwritten form was considered, please document the oral data relied upon by attaching written notes summarizing the conversation or data.
EVALUATION SUMMARY:
Eligibility Criteria and Determination:
In order to be eligible for the rights and protections provided under Section 504 of the Rehabilitation Act, a student must have a physical or mental impairment, which substantially limits one or more major life activity. In order to be eligible for a Section 504 plan, students must be eligible for the rights and protections provided under Section 504 and require reasonable accommodations to access the educational program in a manner similar to his/her non-disabled peers.
ELIGIBILITY
1. Is there documented evidence of a physical or mental impairment? oYes oNo
Specify: ______
2. Does the physical or mental impairment substantially limit a major life activity? oYes oNo
If Yes, please indicate the major life activity where the substantial limitations exists:
oLearning oSpeaking oWalking oBreathing
oSeeing oPerform manual tasks oHearing oCaring for Self
oReading oConcentrating oEating oCommunicating
oThinking oMajor Bodily Function
oOther______
If the answers to questions 1 and 2 are “Yes”, then the student is eligible for the rights and protections provided under Section 504, as outlined in the Parents’ Rights in Brief. If the answer to either question 1 or 2 is “No”, then the student is not eligible.
NEED FOR ACCOMMODATION PLAN
3. Does the eligible student require reasonable accommodations to access the educational program in a manner similar to his/her non-disabled peers? oYes oNo
If the answer to question 3 is “Yes”, the student is also eligible for an accommodation plan, and a plan will be developed.
SUMMARY:
The Section 504 team has determined:
oThe student is not eligible under Section 504.
oThe student is eligible for Section 504 Safeguards and nondiscrimination protection as outlined in the Parents’ Rights in Brief. However, based on the student’s current functioning he/she does not require reasonable accommodations to access the educational program in a manner similar to his/her peers.For this reason, a 504 accommodation plan will not be developed at this time. If the student’s educational needs change and the team determines he/she requires reasonable accommodations, the team will develop a 504 accommodation plan for the student.
oThe student is eligible under Section 504 and will receive a Section 504 Plan.
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