504 Eligibility And Accommodations Form

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504 Eligibility and Accommodations Form
For Office Use Only
Bethel School District. 4640 Barger Dr.
Eugene, Or. 97402
541-689-3280
Not Eligible
Eligible for 504 Protection and Accommodation
Purpose of Today's 504 Meeting: Choose those that apply.
Eligible for 504 Non-Discrimination Protection
only. No Accommodations at this time.
Initial Eligibility Meeting
Now has IEP under IDEA
Initial Accommodation Planning
504 Review Meeting
Changes made to Accommodations
Eligibility
No changes made, updated team members only
Criteria
Transfer 504 to IDEA / IEP
3 Year Re-Evaluation Meeting, includes New Eligibility Statement
3 Year Renewal due date
Today's Date
School Name
Homeroom/ Counselor
Student Name
Grade
Date of Birth
List SST/504 Meeting Participants: Section 504 requires that "a group of persons, including persons knowledgeable
about the child, the meaning of evaluation data, and placement options" make eligibility and placement/services
decisions for students. List name & role (e.g. parent, teacher, principal…) of participants.
Name - Role
Name and Role
Information/Sources Considered in Making the Eligibility Determination:
E.G. medical records, letters from doctors or health care plans; school records; observations of teachers,
paraprofessionals, school administration, school counselors, parents/guardians, and where appropriate, from the
student. This list is not exhaustive. Other sources may include information gathered from a discussion between the
school district's nurse and the student's doctor, assessment by district staff or other professional, and more.
List the Information / Sources Considered

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