San Francisco Unified School District
Student, Family & Community Support Dept.
1515 Quintara St.
San Francisco, CA 94116
(415) 242-2615
Section 504 Eligibility Review Form
(Prior to evaluation for 504, written parent/guardian consent must be obtained. Form 504-1 should be
used for this purpose)
Purpose of Evaluation
At an initial referral for Section 504 plan consideration within MTSS/PBIS interventions
Every three years or sooner for students with existing Section 504 Plans
When there is a request for additional services or evaluation of a new disability
When a student comes from another school with a Section 504 Plan, but there is no evidence of a
Section 504 initial evaluation.
When a student with a Section 504 Plan enters from another district
When considering dropping the services or finding the student is no longer eligible
Date of Evaluation
School of Attendance
Student:
Birth Date:
Address:
City:
Parent/Guardian #1:
Home Phone:
Sex:
Grade:
Student ID#
Ethnicity
Zip:
Parent/Guardian #2:
Cell Phone(s):
Work Phone:
Records Review/Information Gathering:
Describe suspected disability that may be substantially limiting a major life activity
A. Physical Health: Information from health provider, medical reports, Emergency Care Plans. Is there an
impairment that substantially limits one or more major life activities?
B. Mental Health: Information from health provider, medical reports, therapists. Is there an impairment that
substantially limits one or more major life activities?
C. Academic performance: Review grades, teacher comments on report cards, progress reports, SST notes.
Is there evidence that the student has a problem in learning or accessing education? Is there an impairment
that substantially limits one or more major life activities?
SFUSD- Student, Family and Community Support Department
Form 504-4
D. Behavioral: Review discipline records, behavior support contracts, classroom observations, office referrals,
calls to parents regarding behavior. Is there evidence that the student has a problem accessing education? Is
there an impairment that substantially limits one or more major life activities? [Note: If a behavioral (or
mental health disability affecting behavior) is suspected, and no documentation of a disability is available, a
behavioral observation by a school social worker or behaviorist is required before determining eligibility for
a 504 plan.]
Behavioral observation done and report attached.
School psychologist consulted and recommendations attached.
Student does not require further assessment at this time.
Student does require further assessment.
E. Attendance: Review attendance record. What are the causes of attendance problems? Is this an area that
substantially limits one ore more major life activities or access to learning?
F. Evaluation Data: List data considered e.g. CST or other standardized testing, CAHSEE, Brigance scores, any
school wide grade level evaluations, informal evaluations, classroom tests and screenings, outside evaluations
Is the data indicative of a substantial limitation in learning?
G. Previous or Current Interventions: Implementation of previous or current SSTs and/or Section 504 plan
accommodations with fidelity, documentation of interventions including level of success. Are new
interventions needed?
At any time, if this evaluation does not sufficiently demonstrate a disability under Section 504 and/or that
learning (or other major life activities) is significantly impaired, a formal assessment may be indicated.
SFUSD-Student, Family and Community Support Department
Form 504-4
San Francisco Unified School District
Student, Family & Community Support Dept.
1515 Quintara St.
San Francisco, CA 94116
(415) 242-2615
SECTION 504 ELIGIBILITY DETERMINATION MEETING
Use this form for initial eligibility determinations and for re-evaluations
Date of Meeting:
School of Attendance:
Student ID#:
Student & Parent/Guardian Information:
Student:
Birth Date:
Address:
City:
Parent/Guardian #1:
Home Phone:
Sex:
Grade:
Ethnicity:
Zip:
Parent/Guardian #2:
Cell Phone(s):
Work Phone:
List SST/504 Meeting Participants: Section 504 requires that “a group of persons, including persons
knowledgeable about the child, the meaning of evaluation data, and placement options” make eligibility and
placement/services decisions for students.
Name & Role:
Section 504 Eligibility Inquiry: “Does student have a physical or mental impairment that substantially limits
one or more major life activities?” This breaks down into the following questions for the 504 Team to answer
Mental or Physical Impairment: (Document discussion here, including reasoning and what sources of
information were considered. Attach an extra sheet of paper if needed.)
Describe the nature of the suspected mental or physical impairment.
1. Question One: Does the student have a mental or physical impairment (including behavioral issues
that significantly impede the student from accessing education)?
Team Conclusion:
Yes
No
Major Life Activity and Substantial Limitation. (Document discussion here, including reasoning and what
sources of information were considered. Attach an extra sheet of paper if needed.)
SFUSD- Student, Family and Community Support Department
Form 504-4
State what major life activity(ies) is thought to be substantially limited. (Can be more than one.)
Describe how the suspected impairment may substantially limit the above major life activity/-ies.
2. Question Two: Does the impairment(s) substantially limit one or more major life activities?
Team Conclusion:
Yes
No
If both 504 questions 1 & 2 above were answered “Yes,” then the student is eligible for a Section 504 Plan.
The 504 Team analyses of the eligibility questions indicates: (CHECK ONE)
The student is not eligible for services/accommodations under Section 504 as the impairment
does not meet the criteria above.
The student is eligible under Section 504 and will receive a 504 Plan.
The 504 Team should continue on now to develop the 504 Plan appropriate for the student, or
schedule a subsequent meeting for this purpose.
The student is eligible under Section 504 but does not require accommodations/services at
this time.
(Re-evaluation) The student remains eligible under Section 504 and will receive an updated
504 Plan.
(Re-evaluation) The student is no longer eligible under Section 504 and is exited from the
program. Student will receive general education without Section 504.
Signatures of Participants
I agree with the 504 Eligibility Determination as noted above:
Role / Title
Name
Signature
Date
Parent / Guardian
Parent / Guardian
Student (if present)
Administrator
Teacher
Teacher
Teacher
SFUSD-Student, Family and Community Support Department
Form 504-4
School District Nurse
School Social Worker
School Psychologist
Site 504 Coordinator
Notice of Parent/Guardian & Student Rights given to:
on:
by:
1. Place a copy of this 504 Eligibility Determination in the student’s cum file.
2. Send a copy of this 504 Eligibility Determination to:
District 504 Coordinator, Student, Family and Community Support Department, 1515 Quintara St., SF, CA
94116
If Parent/ Guardian Disagrees:
 I do not agree with the 504 Eligibility Determination as noted above, and I have received a copy of my
Parent/Guardian rights including the right to request a Review Hearing within 30 calendar days.
Parent/Guardian Signature_______________________________ Date_______________
SFUSD-Student, Family and Community Support Department
Form 504-4
SAN FRANCISCO UNIFIED SCHOOL DISTRICT
SECTION 504 ACCOMMODATION/SERVICE PLAN
Name of Student:
Grade:
Student ID#:
Initial Plan Date:
Annual Review Date:
Annual Review Date:
Triennial Review Date:
Specific Need:
Accommodations/Services
Start Date
End Date
Start Date
End Date
Start Date
End Date
Start Date
End Date
Start Date
End Date
Start Date
End Date
Who will implement the accommodations
Specific Need:
Accommodations/Services
Who will implement the accommodations
Specific Need:
Accommodations/Services
Who will implement the accommodations
Specific Need:
Accommodations
Who will implement the accommodations
Specific Need:
Accommodations
Who will implement the accommodation
Specific Need:
Accommodations
SFUSD- Student, Family and Community Support Department
Form 504-4
Who will implement the accommodation
Attach additional pages for more accommodations
I agree with the accommodations as noted above in this 504 Plan:
Role / Title
Name
Signature
Date
Parent / Guardian
Parent / Guardian
Student (if present)
Administrator
Teacher
Teacher
Teacher
School District Nurse
School Social Worker
Counselor
School Psychologist
Notice of Parent/Guardian & Student Rights given to:
on:
by:
Next Steps:
1. Give copy of 504 Plan to parent/guardian.
2. Give copy of 504 Plan to appropriate staff.
3. Place a copy of 504 Plan in the student’s cum file.
4. Send a copy of this 504 Plan to:
District 504 Coordinator, Student, Family and Community Support Department,
School Health Programs, 1515 Quintara St., SF, CA 94116
If Parent /Guardian Disagrees:
 I do not agree with accommodations as noted above, and I have received a copy of my
Parent/Guardian rights including the right to request a Review Hearing within 30 calendar days.
Parent/Guardian Signature_______________________________ Date_________________
SFUSD-Student, Family and Community Support Department
Form 504-4