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     Eligibility Determination Form    
                                   

ELIGIBILITY DETERMINATION FORM FOR SECTION 504

I. General Information

Student Name:__________________________________________ Today's Date_______________

Address (Street, City, State, Zip Code): _______________________________________________

_______________________________________________________________________________

School:___________________ Home Phone:_________________ Work Phone:_______________

II. Reason for Meeting

 

Initial evaluation

Periodic re-evaluation

Re-evaluation before significant change in placement

III. Eligibility Criteria and Determination

Yes No        1.   Student has a mental or physical impairment

Yes No        2.  Student's impairment substantially limits a major activity.  Area(s) where
                                  substantial limitation exists: (see Major Life Activity Form)
                                  ______________________________________________________________
                                  ______________________________________________________________

Yes No        3.  Student meets eligibility criteria for 504 determination.

 

IV. Committee Members

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

V. Record of Action

             Date                                            Action

_____/_____/_____  Parents/Guardians provided written notice of rights

_____/_____/_____  Notice of 504 evaluation and committee meeting