Date of Referral: Student: Student ID:

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Iredell-Statesville Schools
Request for Section 504 Consideration
Form 1a
Date of Referral:
Student:
Student ID:
School:
Date of Birth:
Grade:
Teacher:
Person Making Referral:
Position/Relationship:
What sources of evaluation data are available to indicate that this student has a mental or physical
impairment? Check all that apply. Attach copies of applicable evaluation data.
□ Aptitude or achievement tests
□ Adaptive behavior
□ Social or cultural background
□ Parent Information □ Physicians Report
□ Report Cards
□ Physical Condition
□ State Test Results □ other (specify)_____________
Which major life activity is significantly limited by the student’s mental or physical impairment? Check all
that apply.
Seeing
Performing
Manual Tasks
Concentrating
Hearing
Breathing
Sleeping
Walking
Caring for one’s
self
Speaking
Learning
Other
Working
Classroom Performance: Check each area areas in which the student has difficulty at school:
Oral reading
Silent reading
Spelling
Oral expression
Reading
comprehension
Math problem
solving
Writes legibly
Math calculations
Math applications
Written expression
Gross motor skills
Completing
classroom work
Following oral
instructions
Adult relations
Homework
Tests
Following written
instructions
Peer relations
Attention span
Organizational
skills
Concentration
Tendency to
withdraw
Math reasoning
Fine motor skills
Distractibility
Please provide any additional information that you believe would be helpful in determining whether this
student has a disability under Section 504.
Section 504 Office Use Only
Date Received:
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