PINELLAS COUNTY SCHOOLS
SECTION 504 – EVALUATION/REEVALUATION SUMMARY AND ELIGIBILITY DETERMINATION
Student:
ID#:
Grade:
Date of Birth:
Date of Meeting:
School:
For Initial Evaluation - Parent Consent Signed?
No
Yes (Date:
)
For Reevaluation – notice sent?
No
Yes (Date:
)
Notice of Meeting Sent?
No
Yes (Date:
)
Parent and Student Rights Provided?
No
Yes (Date:
)
EVALUATION SUMMARY
Initial Evaluation
’s evaluation for eligibility for Section 504 is summarized as follows:
Evaluation Source
Grades (including any trend
that is evident)
Medical Information,
Evaluations
Discipline records
Work samples
School Health Information
Standardized Tests (FAIR,
common assessments, End of
Course Tests, FCAT,
Diagnostics, etc.)
PS/RtI (Early Intervention)
Data:
Attendance:
Teacher Input:
Student Input:
Parent Input:
Observation:
Related Services:
Reevaluation
Summary/Comments
Reviewer/Evaluator
NOTE: If information from a conversation or other data in unwritten form was considered, please document that
oral data relied upon by attaching written notes summarizing the conversation or data.
Is this a temporary disability?
If yes, the date of the discontinuance of the accommodation plan is
Yes
No
Is there evidence in the evaluation that an impairment exists that is episodic?
If yes, explain:
Yes
No
Is there evidence in the evaluation that an impairment exists that is in remission?
If yes, explain:
Yes
No
ELIGIBILITY DETERMINATION
PCS Form 2-2503 (Rev. 2/15) Page 1 of 3
Revision Date 2/16
Category A
Based on the above evaluation results, the School 504 Committee has determined that
mental impairment.
Yes
If yes, specify the impairment identified by the team:
No
Physical Impairment: Specify Impairment:
has a physical or
Mental Impairment: Specify Impairment:
Yes
No
The impairment identified above substantially limits one or more major life activities or major bodily functions:
(Check all that apply):
A. Caring for Self
K. Sleeping
U. Brain
B. Performing Manual Tasks
L. Standing
V. Endocrine System
C. Walking
M. Lifting
W. Cell Growth
D. Seeing
N. Bending
X. Respiratory Function
E. Hearing
O. Reading
Y. Reproductive System
F. Breathing
P. Concentrating
Z. Digestive System
G. Speaking
Q. Thinking
AA. Neurological System
H. Learning
R. Communicating
BB. Circulatory System
I. Working
S. Immune System
CC. Other:
J. Eating
T. Bowel Function
REQUIRED: If one or more of the above are checked, describe the substantial limitation based on the evaluation data:
The School Section 504 Committee determined (Check one):
Qualification Code “A”: The student is disabled because there is a physical or mental impairment that substantially limits a
major life activity(requires “yes” to both questions above) and services are needed in order that the student’s needs are met as
adequately as those of nondisabled peers. A Section 504 Accommodation Plan will be developed. Reevaluation date:
Qualification Code “B”: The student is disabled but is not in need of a Section 504 Accommodation Plan because the physical
or mental impairment is in remission. The need for a Section 504 Accommodation Plan will be addressed again when the
impairment comes out of remission. Until such time, it is understood that the student is protected by Section 504’s
antidiscrimination provisions and that the student cannot discriminated against on the basis of the disability. Reevaluation date:
Qualification Code “C”: The student is disabled but is not in need of a Section 504 Accommodation Plan because the student’s
needs are met as adequately as those of nondisabled peers based upon the positive effects of mitigating measures currently in
use. The need for a Section 504 Accommodation Plan will be addressed again should the positive effect(s) of the mitigating
measures currently in use no longer exist. Until such time, it is understood that the student is protected by Section 504’s
antidiscrimination provisions and that the student cannot discriminated against on the basis of the disability. Reevaluation date:
Qualification Code “T”: The student is temporarily disabled (duration of 6 months or less) and requires an accommodation
plan. Plan will be discontinued on
.
Qualification Code “Z”: The student is not disabled because there is no physical or mental impairment that substantially limits a
major life activity.
504 Committee Signatures: By regulation, the Section 504 Committee is a group of knowledgeable people. Within the group,
there needs to be persons with knowledge of the child; knowledge of the evaluation data; and knowledge of options. List each
member attending and indicate the area of knowledge each provides.
PCS Form 2-2503 (Rev. 2/15) Page 2 of 3
Revision Date 2/16
Category A
NAME/POSITION/AREA OF KNOWLEDGE/SIGNATURE
Print Name:
NAME/POSITION/AREA OF KNOWLEDGE/SIGNATURE
Print Name:
Position:
Position:
Area of knowledge:
Area of knowledge:
Signature:_________________________________
Signature:_________________________________
Print Name:
Print Name:
Position:
Position:
Area of knowledge:
Area of knowledge:
Signature:_________________________________
Signature:_________________________________
Print Name:
Print Name:
Position:
Position:
Area of knowledge:
Area of knowledge:
Signature:_________________________________
Signature:_________________________________
Print Name:
Print Name:
Position:
Position:
Area of knowledge:
Area of knowledge:
Signature:_________________________________
Signature:_________________________________
Print Name:
Print Name:
Position:
Position:
Area of knowledge:
Area of knowledge:
Signature:_________________________________
Signature:_________________________________
Copy 1 (original) - School 504 folder
PCS Form 2-2503 (Rev. 2/15) Page 3 of 3
Revision Date 2/16
Copy 2 - Parent
District copy: Upload to Focus SIS
Category A