What does your Section 504 EVALUATION & ELIGIBILITY FORM look like?

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It was interesting to me to read what another poster's 504 evaluation and eligibility form looked like in another thread. So I thought I'd post mine and hope that others will too. I think this could be helpful to readers who are beginning the 504 process.

Here's mine: _______________________________________________________

[b]Section 504 EVALUATION AND ELIGIBILITY

X School District[/b]

Today's date: Student's name: Date of Birth: Age: School: Grade:

[b]Evaluation Results[/b]

(box with "X") [b] 1. Academic Assessment Results:[/b] [i](This states each year's GATES Reading score with the corresponding percentile, and each year's state/national testing scores with the corresponding ranking/percentile/category.) [/i]

(box with "X") [b]2. Regular Classroom Performance:[/b] [i]( Listed here are Mariah's grades for each semester plus teacher comments pulled from report cards.)[/i]

(box with "X") [b]3. Social/Emotional/Behavioral Assessment Results:[/b] [i]( A paragraph is included here stating that teachers had not observed any behavioral issues. After some correspondence and persistence, it was included in this section with an additional paragraph describing Mariah's experiences of "social-emotional concerns" related to being assigned seating due to her food allergies.)[/i]

(box with "X") [b]4. Medical/Physical/Sensory Assessment Results:[/b] [i] (This section summarizes 3 letters from the allergist and also lists the SPT/CAP Rast allergy testing scores.) [/i]

(box with "X") [b]5. Other Assessment Results:[/b] [i] Mariah's attendance records were listed here for each year.[/i]

page 2:

[b]Type of Disability[/b]: [i]Peanut allergy/Anaphylactic to nuts/Asthma[/i]

[b]Diagnosing Physician or Psychologist:[/b] [i](Mariah's allergist's name is listed.) [/i]

[b]Check all major life activities that are substantially limited by the disability.[/b] (Please check all that apply.):

[i]Nine life functions are listed:[/i] Walking, Speaking, Working, Seeing, Breathing, Learning, Hearing, Caring for Self, Performing Manual Tasks. [i]"Breathing" is checked with an "X".[/i]

[b] Conclusion:[/b] Student (check one)[b] IS [/b] or [b] IS NOT [/b] currently eligible/disabled under Section 504. If eligible, an Individualized Accommodation Plan will be developed.

IF student has a "record of " a physical or mental impairment which substantially limits one or more major life activities OR is "regarded as having such an impairment", please explain below:

Parent signature: Date: _________________________________________________________

[This message has been edited by Gail W (edited March 05, 2006).]

On Mar 5, 2006

Gail - Great idea!!

Here is our form....as completely by our ignorant district....idiots!! I'm anxious to see other evaluation forms as well.

XYZ School District Section 504 Evaluation, Eligibility and Accommodation Plan

[b]I. General Information[/b] Student Name: Grade: Today

On Mar 5, 2006

From here: [url="http://uumor.pair.com/nutalle2/peanutallergy/Forum7/HTML/002242.html"]http://uumor.pair.com/nutalle2/peanutallergy/Forum7/HTML/002242.html[/url]

Quote:

Originally posted by Carefulmom in another thread:

[b]The 504 eligibility form was filled out by the nurse. Here is what it said. Paper says: "Eligibility Under Section 504 Does the student have a potienitally limiting mental or physical condition? If yes, describe the nature of the condition."

Nurse checked Yes box and wrote: "Potentially life threatening allergies to milk, egg, and peanuts."

She underlined the word "peanuts" twice. She must have realized that allergy is more life threatening than milk and egg.

Paper says: "Does the student`s condition impair a major life activity? If yes, describe how."

Nurse check Yes box and wrote: "Potential respiratory arrest"

Paper says: "Is the degree of impairment significant? If yes, explain how."

Nurse checked Yes and wrote: "Potentially life threatening."

Then there is a section that says the Section 504 team has reviewed the info and there is a box for meets 504 eligibility criteria and a box for does not. She checked the box for does.

Paper says: "Does the student`s condition require any accomodations in order for the student to access a free and appropriate education?"

Nurse checked Yes.

Then there is a section on discipline, whether her disability would require her to violate school rules or not. She checked that it would not require dd to violate school rules.[/b]

[This message has been edited by Gail W (edited March 05, 2006).]

On Mar 5, 2006

The eligibility form that hopefully we'll get to use one of these days :-)

SECTION 504 ELIGIBLITY DETERMINATION

Name:__________ Birthdate:________ Parents:_______ Age:_______ Address:_______ Grade:_________ Phone:_________ School:_________

Participant Signature: Position: ____________________ __________ ____________________ __________ ____________________ __________

Sources of evaluation information: (indicate each one used) _________Achievement tests _________Adaptive behavior _________Medical Report _________teacher recomm./observations _________student work samples _________cognitive assessments _________other (specify)

Current Performance Levels:_____________________________________________________________________________________________________________________________

Specify the mental or physicial impairment: ____________________________________________

Does the mental or physical impairment affect a major life activity such as learning? ___Yes ___No

___Student is eligible for Section 504. State Reason: (basis for determining eligiblity) ________________________________________________________________________________________ *Records, evaluations, and/or documentation supporting elibility attached __Yes __No

*If eligible under medical criteria - Must attach current medical status reprots indicating condition from attending medical physician.

____Student is ineligible for Section 504. State reason:_________________________________________________________________________________

Accommodations Plan (See attached)

Follow-up Dates: ____Review _____Re-Eval

____I/we have been fully informed of my/our due process (parent rights) and have received copies of them.

____I/we agree with this 504 pland and understand that it will be put into effect.

____I/we disagree with this 504 plan and do not accept recommended accommodations/services at this time.

Legal Parent/Guardian or Adult Student:_____________________________

Date:_________________________

On Mar 5, 2006

Isn`t it interesting that bandbmom`s form for Eligibility also asks if the parent agrees with the accomodations? Bandbmom, do I understand that correctly? Isn`t that sort of proof that they are not following the rules? Gail W, you are the expert---what do you think? Also, just had to comment on the question about does it affect "a major life activity such as learning". Hello, what about breathing or eating? That seems a little strange to me.

On Mar 6, 2006

Want to laugh??? I think this is what the district is using... one of the forms I finally received... blank. This is what they sent me as Policy and Procedures...

Notice of Recommended Agreement of Protected Handicapped Student

Dear __________________

T Area School District has identified your child, ________________ as a Protected Handicapped student.

A service agreement has been developed setting forth the specific related aids, services or accommodations to be provided to ___________________________. A copy of the Service Agreement is attached. Before services can be provided, you must execute the Service Agreement attached.

You have a right to inspect and review all of "you" child's records. You also have the right to meet with school officials to discuss the issues associated with evaluating or accommodating "you" child needs.

Before the Service Agreement is implemented, if you disagree with the content of the Agreement, you have the right to request assistance from the Department of Education, and an informal conference with a school district representative. You also have the right to request a formal hearing before an impartial hearing officer appointed by the State Secretary of Education, or you may file suit in Federal Court under Section 504 of the Rehabilitation Act. Attached is a copy of the regulations governing your rights.

...if you approve the identification of your child as a protected handicapped student, please indicate on the next page (line 1) and sign this form. ...if you approve the content of the Recommended Agreement, please indicate this on the next page (line 2) and sign this form and the Service Agreement. ...if you do not approve of the identification of your child or the contents of the Recommended Agreement, please indicate such and sign both documents. Please list the reasons for your disapproval. (lines 3 & 4)

If you approve the Recommended Agreement, it will not be modified or terminated without your written consent. Please return a copy of these forms (Notice of Recommended Agreement of Protected Handicapped Student and Service Agreement)

Page 2 reads:

Please respond with five (5) days if this was given to you in person or within ten (10) days if you received this by mail. Please return the form to: District address here

If you have any questions or would like further information contact the above name.

(1) _____ I approve the identification of my child as a Protected Handicapped student. (2) _____ I approve the identification of the attached Recommended Agreement. (3) _____ I do not approve the identification of my child as a Protected Handicapped student and (REQUEST) (DO NOT REQUEST) an informal conference with school district officals. (4) _____ I not not approve the contents of the Recommended Agreement and (REQUEST) (DO NOT REQUEST) an informal conference with school district officials. (5) _____ I request a formal due process hearing.

Date ____________ Signature of Parent/Guardian __________________

Attachment I have received a copy of Procedural Safeguards __________

Do you think... this was just written for my upcoming meeting or do you think this was written 50 years ago when they HAD to have something place??? Pathetic isn't it?

I may have made some typing errors.. I put in " " what their typos are in this document!

------------------ Lisa Mom to Mason (peanut/tree nut/sesame/mustard)

On Mar 6, 2006

These are so interesting to me.

Quote:

Originally posted by mommatomase: [b]Do you think... this was just written for my upcoming meeting or do you think this was written 50 years ago when they HAD to have something place??? [/b]

I don't think this is their 'evaluation' paperwork/form. This looks like it's somehow related to their obligation to do "child find". Very confusing.

On Mar 6, 2006

I agree, it is NOT an evaluation form... it is a NORA... nothing to do with evaluation. I can't wait to ask them how they document their findings or come up with their findings... BUT... that's what they sent me.

Could I email you the 504 I have been working on... would you read it for me and let me know what you think??? Thanks... that is if you have time. :-)

------------------ Lisa Mom to Mason (peanut/tree nut/sesame/mustard)

On Mar 6, 2006

Quote:

Originally posted by Carefulmom: [b]Isn`t it interesting that bandbmom`s form for Eligibility also asks if the parent agrees with the accomodations? Bandbmom, do I understand that correctly? Isn`t that sort of proof that they are not following the rules? [/b]

Do you mean something like discrimination/segregation by parental request/consent?

Quote:

Originally posted by Carefulmom: [b]Also, just had to comment on the question about does it affect "a major life activity such as learning". Hello, what about breathing or eating? That seems a little strange to me. [/b]

More than strange, IMO. One of the big myths is that 'learning' must be affected in order to qualify under 504. My SD stated this to me too. This form seems to reflect that Tracy's SD has this misunderstanding. The law states an "impairment which substantially limits one or more major life activities". Tracy will need to show them that the law does not require 'learning', nor 'learning plus another major life activity', in order to qualify. Her doctor letter must/will show how anaphylaxis by definition affects several life activities and qualifies her son for the designation.

On Mar 6, 2006

Quote:

Originally posted by mommatomase: [b]Could I email you the 504 I have been working on... would you read it for me and let me know what you think??? Thanks... that is if you have time. :-)[/b]

What would you think about starting a new thread in 'schools' and asking for input? I think you'll get lots of great feedback from lots of posters here.

On Mar 6, 2006

I really think that the advisory statement and parental refusal of services is there as a general CYA for the school district.

It really isn't soemthing I can disagree with. If your child is covered under 504 but for whatever reason (temporary nature of disability, perhaps, or desire for privacy for your child?) you do NOT want the SD to provide care or services related to it... then the SD has a record saying that THEY tried to do the "right thing" and you said no thanks.

In extreme cases, this has been used as grounds for DHS to take legal action against parents who have decided to homeschool severely disabled children and (according to the school) not provide them with appropriate interventions. Ultimately, though, it is usually up to the parents to choose what they want. But the school district has a parallel obligation to locate and evaluate such children. ( [img]http://uumor.pair.com/nutalle2/peanutallergy/rolleyes.gif[/img] ) Righhhhht. SD officials [i]all go out of their way to find eligible children...[/i]

Anyway, that is what I think the explanation is. Because even HSed kids are supposed to be identified and evaluated because they are still eligible for services.

On Mar 6, 2006

Here's our eligibility form/504 plan. (Yes, all in one short document!)

Student Name_________________

Type of Plan/Meeting_________________

Specific disabling conditions(s)____________

Describe the basis for the determination of the above disability:_____________________

What major life activity is limited:________

Describe how the disability affects this major life activity:___________________

Is this student eligible for Section 504 accommodations? _____Yes _____No

If not, what is the rationale for denying eligibility. Describe how the team determined the student was not eligible:______________________

Describe the necessary reasonable accommodations:_________________________

Review/Reassessment date (Must be completed)____________________

Participants' Signatures Titles Dates

On Mar 6, 2006

Quote:

Originally posted by bandbmom: [b]The eligibility form that hopefully we'll get to use one of these days :-)

SECTION 504 ELIGIBLITY DETERMINATION . . .

Sources of evaluation information: (indicate each one used)

_________Medical Report

*Records, evaluations, and/or documentation supporting elibility attached __Yes __No

*If eligible under medical criteria - Must attach current medical status reprots indicating condition from attending medical physician.

[/b]

This MAY have been discussed here or elsewhere, but I find it quite telling that the form requires "MEDICAL REPORT" &/or "MEDICAL STATUS REPORT" but NOWHERE does it require FULL MEDICAL RECORDS.

Sorry if this is a repeat question -- Who does "Medical Report"?? Is that a form completed by child's physician(s) and then provided to school district? Or is "Medical Report" something created by someone in school district after he/she/they do own review and interpretation (or MISinterpretation) of child's full medical record that they've been so rabid in requiring??!!!

Just me, wondering.

Elizabeth

On Apr 20, 2006

Raising for a friend

On Apr 21, 2006

Gail - if you raised for me thank you [img]http://uumor.pair.com/nutalle2/peanutallergy/smile.gif[/img] if not, thank you anyway [img]http://uumor.pair.com/nutalle2/peanutallergy/smile.gif[/img] [img]http://uumor.pair.com/nutalle2/peanutallergy/smile.gif[/img]

I will type what our school district uses omorrow - I do happen to have it from the meeting, when they wanted me to show them exactly what I thought needed to be filled out on it??!!??

Thx, [img]http://uumor.pair.com/nutalle2/peanutallergy/smile.gif[/img]

On Jun 27, 2006

I'm sorry. Had to delete...

[This message has been edited by Lori Anne (edited June 11, 2007).]

On Jun 27, 2006

deleted. Sorry.

[This message has been edited by Lori Anne (edited June 11, 2007).]

On Jun 27, 2006

deleted.

[This message has been edited by Lori Anne (edited June 11, 2007).]

On Jul 14, 2006

As per request, here is the original 504 plan form from our SD. --------------------------------------- --------------------------------------- __________ County Schools 504 Plan

Student ___________________ Date _________ School _______________________________

Eligibility Determination

The 504 Eligibility Committee determines that the student: _____ Meets the eligibility criteria of having a mental or physical impairment in the following area(s): _____ Alcohol/Drug Addiction _____ Attention Deficit Disorder _____ Communicable Disease _____ Temporarily Injured _____ Physically Disabled _____ Socially Maladjusted _____ Other Health Impaired _____ Other _____________________________

_____ Meets the criteria that the impairment substantially limits one or more major life activities:

_____ Caring for One's Self _____ Breathing _____ Seeing _____ Hearing _____ Performing Manual Tasks _____ Walking _____ Working _____ Speaking _____ Learning

_____ Is Eligible for services under Section 504 of the Rehabilitation Act of 1973. _____ Is NOT Eligible for services under Section 504 of the Rehabilitation Act of 1973.

ACCOMODATION PLAN

SERVICES RECOMMENDED _____ School Health Services _____ Physical Therapy _____ Counseling _____ Regular Education Modification _____ Transportation _____ Occupational Therapy _____ Other

504 Plan: (Modifications) ________________________________ ________________________________

Projected Date of Periodic Reevaluation _______

504 Eligibility Committee Members (must consist of three members) [signatures] Administrator _____________________ Current Teacher____________________ Parent ____________________________ Other _____________________________

----------------------------------------- -----------------------------------------

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