St. Joseph School District
504 Evaluation / Re-Evaluation Report
Date of Report
Student:
School/Grade:
Parent(s):
Address:
Phone Number:
Has student been previously evaluated for eligibility under IDEA?
Medical History:
Physician:
Date of Diagnosis / Documentation:
Current Diagnosis:
Indicators of Real and Ongoing Condition: <Select as applicable, and erase others: classroom
observation, medical report, pharmacy records, health clinic records, hospitalization records;
physician’s health records;…. >
Evaluation Method: 504 Substantial Limitation Rating Scale / Classroom Observations
Evaluator (s):
Findings:
When compared to the average, typical non-disabled peers, ___ of ___ teachers rated the student’s
impairment impact as good or better in the Major Life Activity of : Breathing, Caring for
Oneself, Hearing, Learning (in all areas), Performing Manual Tasks, Seeing, Speaking, Walking,
Eating, Sleeping, Standing, Lifting, Bending, Reading, Concentrating, Thinking, Communicating,
Operation of a Major Bodily Function
When compared to the average, typical non-disabled peers, ___ of ___ teachers rated the student’s
impairment impact as weaker in the Major Life Activity of : Breathing, Caring for Oneself,
Hearing, Learning (in all areas), Performing Manual Tasks, Seeing, Speaking, Walking, Eating,
Sleeping, Standing, Lifting, Bending, Reading, Concentrating, Thinking, Communicating,
Operation of a Major Bodily Function
When compared to the average, typical non-disabled peers, ___ of ___ teachers rated the student’s
impairment impact as substantially in the Major Life Activity of : Breathing, Caring for Oneself,
Hearing, Learning (in all areas), Performing Manual Tasks, Seeing, Speaking, Walking, Eating,
Sleeping, Standing, Lifting, Bending, Reading, Concentrating, Thinking, Communicating,
Operation of a Major Bodily Function
Summary of Findings
Impairment(s) that substantially limit a major life activity:
Major Life Activity impacted:
Description of how the impairment interferes with the student receiving / accessing an
education:
Referral Review Team Members (Group of persons knowledgeable about the student, the
meaning of the evaluation data, and the placement options)
Name
Role
Name
Role
Name
Role
Name
Role
Name
Role