Request For Medical Information For Section 504 Evaluation - Form 504 F
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AIRBANKS
ORTH
TAR
OROUGH
CHOOL
ISTRICT
520 Fifth Avenue
Fairbanks, Alaska 99701-4756
(907) 452-2000
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Request for Medical Information for Section 504 Evaluation –
Form 504 F
Date: _________________
Health Care Provider/Facility: ____________________________________________________
Address: _____________________________________________________
_____________________________________________________
Student’s Full Name: ____________________________________ Date of Birth: ___________
Dear Health Care Provider:
The above named student has been referred for evaluation and consideration of eligibility for
Section 504 accommodations due to physical or mental impairment. Please provide the following
information and return to the person indicated below. If the person indicated is not the student’s
parent, a Consent for Release of Information – Form 504 E is attached. Thank you for your
timely provision of this information.
1. Student’s medical diagnosis______________________________________________
a. Is the disability/impairment temporary?
yes
no
b. If temporary, what is the anticipated duration? _____________________
2. Please check which major life activities, or identify which other bodily functions are
affected:
Seeing
Reading
Learning
Hearing
Thinking
Walking
Speaking
Concentrating
Breathing
Caring for Oneself
Other: ____________________________________________________
Other Bodily Functions: ______________________________________
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