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Section 504 Eligibility Determination

Student Name______Date______

1. Does the student have a physical or mental impairment? If so, Please identify the impairment in the box below. Note: This is an educational determination only, and not a medical diagnosis for purpose of treatment.
_____Yes _____No
If you answered “yes” to Question 1, identify the impairment here.
2. Does the physical or mental impairment affect one or more major life activities? If so, identify the major life activity or activities affected. _____Yes _____No
If you answered “yes” to Question 2, identify the major life activity(ies) impacted here.
3. Does the physical or mental impairment substantially limit a major life activity? That is, as a result of the physical or mental impairment, is the student significantly restricted as to the condition, manner or duration under which the student can perform a particular major life activity as compared to the condition, manner, or duration by which the average student of the same age/grade level in the general population can perform that same major life activity? If yes, describe the substantial limitation in the below.
_____yes _____no
If you answered “yes” to Question 3, describe how the student is substantially limited here.
4. Does the student need Section 504 services in order for his/her educational needs to be met as adequately as those of non-disabled peers? (Note: if the student’s needs are so extreme as to require special education and related services, a referral to special education should be considered.)
_____yes _____no
If all four questions are answered “Yes”, the student is eligible for a free, appropriate public education under §504, and the Individual Accommodation Plan should be developed. If any answer is “No”, the student is not eligible.

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)

The student is not eligible for services under Section 504.
The student is eligible under Section 504, and will receive and IAP that governs the provision of a free appropriate public education to the student.
The student is eligible under Section 504; however, needs no accommodations at this time. (ADHD)
The student remains eligible under Section 504, and will receive an updated IAP that governs the provision of a free appropriate public education to the student. (3-year evaluations)
The student is no longer eligible for Section 504 according to the re-evaluation. Exit date:______
The student will be evaluated by Special Education Team and if the student meets guidelines, will receive services through Special Education.

____Parent/Student Rights Attached Renee’ Durio, Section 504 Coordinator Tangipahoa Parish School System –Revised- August 2010

(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. Use original dates for 1-4.

a. SBLC suspects Characteristics of Dyslexia Date______

b. Dyslexia Assessment (Screening Specialist)

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)

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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