Eligibility Team Members: Fill in names and check areas of knowledge for each member: Names: Student Evaluation Data Accommodations/Supports Options Note: Make sure there is at least one check in each column Sources of evaluation information (check each one used): Physician Observational tools Social/Emotional Checklist Specialist Teacher recommendations Academic Assessments Family Interview Others (specify): Adaptive Behavior Tools Review of school records 1. *Specify the mental or physical or limitations to bodily functions: impairment, (as recognized in DSM-V or other respected source, excludes illegal drug use) 2. Check the major life activity which is impacted (Must be related to participation in school activities): Seeing Manual tasks Eating Standing Other (specify) Reading Walking Speaking Lifting Social/behavioral Concentrating Breathing Bending Hearing Working Self-care Communicating Thinking Learning Sleeping Sitting Reaching Interacting Reaching w/others 3. Place an on the following scale to indicate the specific degree that the impairment (in #1) limits the major life “X” activity (in #2): (Use the rubric of Impact of Disability on School Activities” to assist in establishing level of “Level impact) Fill in specific information from rubric that justifies the rating: Extremely Substantially Moderately Mildly Negligibly Student is Eligible for 504 Service Plan Not Eligible Distrito Escolar RESUMEN DE ELEGIBILIDAD DE LA SECCION 504 Nombre del Estudiante: Fecha de Nacimiento: Miembros del Equipo de Elegibilidad: Llene los nombres y marque las áreas de verificación del conocimiento de cada miembro:
Eligibility Team Members: Fill in names and check areas of knowledge for each member: Names: Student Evaluation Data Accommodations/Supports Options Note: Make sure there is at least one check in each column Sources of evaluation information (check each one used): Physician Observational tools Social/Emotional Checklist Specialist Teacher recommendations Academic Assessments Family Interview Others (specify): Adaptive Behavior Tools Review of school records 1. *Specify the mental or physical impairment, or limitations to bodily functions: (as recognized in DSM-V or other respected source, excludes illegal drug use) 2. Check the major life activity which is impacted (Must be related to participation in school activities): Seeing Reading Social/behavioral Hearing Thinking Reaching Manual tasks Walking Concentrating Working Learning Interacting w/others Eating Speaking Breathing Self-care Sleeping Standing Lifting Bending Communicating Sitting Reaching Other (specify) 3. Place an “X” on the following scale to indicate the specific degree that the impairment (in #1) limits the major life activity (in #2): (Use the rubric “Level of Impact of Disability on School Activities” to assist in establishing level of impact) Fill in specific information from rubric that justifies the rating: Extremely Substantially Moderately Mildly Negligibly Student is Eligible for 504 Service Plan Not Eligible Distrito Escolar RESUMEN DE ELEGIBILIDAD DE LA SECCION 504 Nombre del Estudiante: Fecha de Nacimiento: Miembros del Equipo de Elegibilidad: Llene los nombres y marque las áreas de verificación del conocimiento de cada miembro:
Section_504_Handbook_January_2014.docx