MESA PUBLIC SCHOOLS
SECTION 504 ELIGIBILITY DETERMINATION REPORT
Student Name:_________________________
School: ___________________________
ELIGIBILITY:
1.
Yes
No
2.
Yes
No
3.
Yes
No
Student #: _________ Grade Level: ___
Date: ________
[ ] Initial Section 504 Evaluation [ ] Section 504 Re-evaluation
Based on the evaluation data gathered from a variety of sources, the Section 504 Team answered the
following questions to determine Section 504 eligibility.
Does the student have a physical or mental impairment? If so, check the impairment. The Section 504 regulations define a
“physical or mental impairment ” as any physiological disorder or condition, cosmetic disfigurement or anatomical loss
affecting one or more of the following body systems:
neurological,
musculoskeletal,
special sense organs,
respiratory,
speech organs
digestive,
genito-urinary,
hemic and lymphatic,
skin or endocrine, or any mental or psychological
disorder such as
mental retardation,
organic brain syndrome,
emotional illness,
mental illness,
specific learning
disabilities, or
other. If “other,” then state: ____________________________________________.
Does the physical or mental impairment affect one or more major life activities? If so, which major life activity
or activities are affected? To fall within the protection of Section 504, a student’s physical or mental impairment must have a
substantial limitation (permanent or temporary) on one or more major life activities:
caring for oneself,
performing
manual tasks,
walking,
seeing,
hearing,
speaking,
breathing,
learning,
working, eating,
sleeping, standing,
lifting,
bending,
reading,
concentrating,
thinking,
communicating,
other. If “other” then state: _______________________________.
Does the physical or mental impairment SUBSTANTIALLY limit a major life activity? That is, as a result of
the physical or mental impairment, is the student significantly restricted as to the condition, manner or duration under which the
student can perform a particular major life activity as compared to the condition, manner or duration under which the student of
the same age/grade level in the general population can perform that same major life activity? Use the following questions only
to support the 504 Team’s determination of a substantial limitation.
On District outcome assessments, are student’s skills markedly below average?
On grade reports, is there an overall pattern of poor grades (significantly below average  D’s and F’s)?
On group-administered standardized achievement tests, does student score below average?
Has student received disciplinary action for inappropriate behavior?
Does student have special health care needs (medication, allergy, etc.) during class activities, including lunch?
Does student have a pattern of excessive absences and/or tardies?
Other
If all three questions were answered “Yes,” the student is eligible under Section 504, and an Accommodation Plan should be
developed. If 2 and/or 3 is “No,” the student is not eligible for a 504 Plan but is considered ‘technically eligible’ and has nondiscriminable protections.
(Optional)
4.
Other
The 504 Team has NOT identified this student as eligible for a 504 Accommodation Plan. However, they recognize this student
may be struggling and suggest the following explanation:
SOURCES OF DATA: (Check the data obtained for the evaluation. All data obtained must be carefully considered.)
Grades
Parent Report
Classroom Teacher(s) Report
School Records
Medical Reports
Individual Achievement Tests
Work Samples
IEP (date)
Group Achievement Test
Other
Psycho-educational Evaluation (date)
TEAM OF EVALUATORS:
Name
Title
Agree
Disagree
CURRENT STATUS:
Has a 504 Plan (Code = 4)
Was evaluated for 504 but did not qualify (Code = 3)
“Technically Eligible” – no 504 Plan (Code = 5)
504 Plan terminated due to:
No longer eligible (Code = 5)
Parent withdrawal (Code = 5)
Eligible for Special Ed (Code = 2)
Send hard copy of this completed form to the District 504 Coordinator at the Student Services Center.
504-5 (Rev. 9/12)