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Lincoln County Schools
Section 504 Initial Disability Determination & Reevaluation
CHECK ONE: ___Initial Determination
___Reevaluation
Revised – July 2015
Student’s name: ___________________________________Grade:_____ Today’s Date:_________________
Notice of Section 504 Parental Rights sent to parent:
(date sent:___________)
For Reevaluation ONLY: Section 504 Review/Reevaluation Notice sent to parent:
(date sent:___________)
Section 504 Team Membership:
The 504 Team must include persons knowledgeable of the student, the evaluation data and placement options. Each area of
knowledge must be represented on this team.
504 Team Members Signature
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
Printed Name and Title
___________________________________________
___________________________________________
___________________________________________
___________________________________________
___________________________________________
___________________________________________
The Team reviewed and carefully considered data gathered from a variety of sources, including the referral document.
Please check each type of data reviewed by the Team (and attach copies of any relevant data).
___Teacher Observations
___Parent Observations
___Review of School Records
___Health Information
___Standardized Assessments ___Grades
___Language Survey
___Disciplinary Referrals
___Social or Cultural Information
___Parent Input
___Early Intervention Data
___Other_________________________
**If information from a conversation or other data in an unwritten form was considered, please document that oral data by
attaching written notes summarizing the conversation.
Disability Determination:
Question 1: Does the student have a mental or physical impairment?
This is an educational determination only, and not a medical diagnosis for the purpose of treatment. Impairments that are
episodic, in remission or are mitigated should also be considered.
OCR guidance suggests that in “virtually every case” diabetes, epilepsy, bipolar disorder and autism will result in eligibility
under Section 504. Extensive documentation of these impairments should not be required.
Does the student have a physical or mental impairment?
YES NO
If the answer is YES, is the impairment: MENTAL PHYSICAL
What is the impairment _______________________________________________________________________?
Question 2: Does the physical or mental impairment affect one or more major life activities or major bodily
functions? What is the major life activity impacted?
__seeing __hearing __walking __learning __breathing __concentrating __thinking __reading
__communicating __eating __sleeping __standing __lifting __bending __caring for oneself
__functions of the immune system __bowel function __bladder function __digestive function
__neurological function __brain function __respiratory function __circulatory function
____other ( _____________________________________________________________________________________)
© 2015 – Mary Moren
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Question 3: Does the physical or mental impairment substantially limit a major life activity?
Considerations:
 Focus on the major life activity as a whole (e.g. learning), not in a particular class (e.g. math), or for a particular
sub-area (e.g. socialization)
 Discount from the consideration sub-par performance due to other factors such as; normal moods, lack of
motivation and the immediate situation or environment.
 Is this person substantially limited in performing a major life activity as compared to the “average student” of the
same grade or age?
 Make an educated estimate without the effects of mitigating measures.
Does the physical or mental impairment substantially limit a major life activity or major bodily function?
YES
NO
If “NO” explain why the student is not substantially limited: _______________________________________________
___________________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________ is/is not eligible for 504 protection. (circle either “is” or “is not”)
If the team’s determination is that the student meets the criteria to be considered disabled, and if deemed necessary, the
team will develop a plan which outlines appropriate accommodations necessary for the student to have educational
opportunities equal to their non-disabled peers.
Considerations:
 If the student’s impairment is in remission and creates no need for services or accommodations, the student is not in
need of an accommodation plan.
 If the student’s needs are currently addressed by mitigating measures with no need for additional services or
accommodations, and the mitigating measures are provided by the student or parents, with no action required by the
school, the student is not in need of an accommodation plan.
_____________________ is/is not in need of an accommodation plan at this time. (circle either “is” or “is not”)
Results Analysis:
Not §504 Eligible: This student is not eligible under Section 504.
§504 Eligible and No Plan: This student is eligible under Section 504 but will not require a Section 504 Accommodation
Plan. The student will receive manifestation determination, procedural safeguards, periodic re-evaluation as needed, and
the nondiscrimination protections of Section 504.
§504 Eligible with Plan: The student is eligible under Section 504 and will receive a Section 504 Accommodation Plan
that governs the provision of a free and appropriate public education, in other words, provides accommodations that would
be required for him/her to have access to his/her education that is equal to non-disabled peers. Additionally, the student
will receive manifestation determination, procedural safeguards, periodic re-evaluation as needed, and the
nondiscrimination protections of Section 504.
Place a copy of this form in the student’s Section 504 folder
© 2015 – Mary Moren