504 Eligibility And Accommodations Form Page 2
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4Eligibility Form: Required for Initial Eligibility and 3 Year Re-Evaluation
1. Mental or Physical Impairment:
Does the student have a current physical or mental impairment under section 504? Or a history of such impairment?
(as recognized in DSM-IV or other respected source, if not excluded under 504/ADA, e.g., legal drug use).
Section 504 Eligible impairments may include, but are not limited to:
ADD /ADHD, Anxiety Disorder, Autism, Bipolar Disorder, Diabetes, Epilepsy, Life Threatening Allergies, etc.
No. There is no impairment and no history of such impairment. Stop. Not Eligible for 504.
Yes. This may
include students with
a history of an
impairment.
Explain /Describe
Physician's Eligibility Statement is on file? Y / N
2. Major Life Activities and Substantial Limitation
:
Does the student's impairment substantially limit one or more major life activities? The determination of whether a
disability substantially limits a major life activity is subjective. Section 504 Law and the ADA do not provide any
operational criteria of substantial limitation. Teams must use their collective, professional judgment to make the
decision.
A. Therefore, compared to the average student of the same grade level, describe which major life activities are
limited:
Seeing
Reading
Thinking / Problem Solving
Performing Manual Tasks
Hearing
Concentrating / Focus
Caring for Oneself, Other Bodily Functions
Eating
Speaking
Learning
Other,
Sleeping
Communicating
please explain:
Breathing
Walking
B. Describe how the suspected impairment may substantially limit the above major life activities.
1. Do not consider medication, assistive devices or other mitigating factors; 2. compare to average student; c. if episodic or in remission,
determine impact when active. (Document discussion here, including reasoning and what sources of information were considered. Attach an
extra sheet of paper if needed.)
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