"Section 504 Eligibility Determination" - Georgia (United States)

Section 504 Eligibility Determination is a legal document that was released by the Georgia Department of Education - a government authority operating within Georgia (United States).

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  • Released on August 1, 2018;
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                                                                                   Section 504 Eligibility Determination
 
 
S
1
S
I
 
ECTION 
 
 
TUDENT 
NFORMATION
 
_______________________________________________           ______________________         ____________________ 
Student Name                                                                                        GTID                                                 Birthdate                                
 
___________________________________________________________          ________              ____________________ 
School                                                                                                                                Grade                    Meeting Date 
 
S
2
S
504
E
T
M
(
)
ECTION 
 
 
ECTION 
 
LIGIBILITY 
EAM 
EMBERS 
SIGNATURES
 
____________________________________________________            __________________________________________________ 
Parent                   
 
 
 
 
 
Administrator 
 
____________________________________________________            __________________________________________________ 
Student   
 
 
 
 
 
 
School Nurse 
 
____________________________________________________            __________________________________________________ 
Teacher   
 
 
 
 
 
 
School Psychologist/Guidance Counselor 
 
____________________________________________________            __________________________________________________ 
Teacher   
 
 
 
 
                               Other 
S
3
S
/R
I
I
 
ECTION 
 
 
USPECTED
EPORTED 
MPAIRMENT 
NFORMATION  
 
A. Under Section 504, a student with a disability is defined as a person who: (1) has a physical or mental 
impairment that substantially limits a major life activity; (2) has a record of such an impairment; or (3) is 
regarded as having such an impairment. Please list the suspected/reported physical or mental 
impairment(s) below: 
 
 
____________________________________________________ 
_________________________________________________ 
Suspected/reported physical or mental impairment   
 
Suspected/reported physical or mental impairment 
 
B. The impairment(s) above limits at least one of the following major life activities: 
 
☐Caring for one’s self  
☐Hearing  
☐Learning 
☐Performing manual tasks  
☐Speaking  
☐Other _____________
☐Walking  
☐Breathing  
☐Seeing  
☐Working  
 
 
 
☐  permanent 
C. The suspected/reported impairment(s) is/are:        ☐episodic                ☐temporary   
 
Page 1 
Georgia Department of Education
Model Form | August 2018
                                                                                                                                                                                          
                                                                                    
                                                                                   Section 504 Eligibility Determination
 
 
S
1
S
I
 
ECTION 
 
 
TUDENT 
NFORMATION
 
_______________________________________________           ______________________         ____________________ 
Student Name                                                                                        GTID                                                 Birthdate                                
 
___________________________________________________________          ________              ____________________ 
School                                                                                                                                Grade                    Meeting Date 
 
S
2
S
504
E
T
M
(
)
ECTION 
 
 
ECTION 
 
LIGIBILITY 
EAM 
EMBERS 
SIGNATURES
 
____________________________________________________            __________________________________________________ 
Parent                   
 
 
 
 
 
Administrator 
 
____________________________________________________            __________________________________________________ 
Student   
 
 
 
 
 
 
School Nurse 
 
____________________________________________________            __________________________________________________ 
Teacher   
 
 
 
 
 
 
School Psychologist/Guidance Counselor 
 
____________________________________________________            __________________________________________________ 
Teacher   
 
 
 
 
                               Other 
S
3
S
/R
I
I
 
ECTION 
 
 
USPECTED
EPORTED 
MPAIRMENT 
NFORMATION  
 
A. Under Section 504, a student with a disability is defined as a person who: (1) has a physical or mental 
impairment that substantially limits a major life activity; (2) has a record of such an impairment; or (3) is 
regarded as having such an impairment. Please list the suspected/reported physical or mental 
impairment(s) below: 
 
 
____________________________________________________ 
_________________________________________________ 
Suspected/reported physical or mental impairment   
 
Suspected/reported physical or mental impairment 
 
B. The impairment(s) above limits at least one of the following major life activities: 
 
☐Caring for one’s self  
☐Hearing  
☐Learning 
☐Performing manual tasks  
☐Speaking  
☐Other _____________
☐Walking  
☐Breathing  
☐Seeing  
☐Working  
 
 
 
☐  permanent 
C. The suspected/reported impairment(s) is/are:        ☐episodic                ☐temporary   
 
Page 1 
Georgia Department of Education
Model Form | August 2018
                                                                                                                                                                                          
                                                                                    
                                                                                   Section 504 Eligibility Determination
 
 
S
4
E
I
 
ECTION 
 
 
VALUATION 
NFORMATION
 
A. The following were reviewed/administered as part of the Section 504 eligibility process: 
 
☐Standardized test scores  
☐Discipline records 
☐Psychological assessment 
☐Student work samples 
☐Adaptive behavior assessment 
☐Cognitive assessment 
☐Medical diagnosis/assessment 
☐Teacher recommendations/observations 
☐Academic records/grades 
☐Parent input 
☐Physical condition information 
☐Section 504 Pre‐referral data 
☐Social or cultural background 
☐Other ____________________________ 
 
 
B. Provide a clear, concise description of results from assessments/data that were reviewed. 
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________ 
 
Page 2 
Georgia Department of Education
Model Form | August 2018
                                                                                                                                                                                          
                                                                                    
                                                                                   Section 504 Eligibility Determination
 
 
S
5
P
D
 
ECTION 
 
 
LACEMENT 
ECISION
In accordance with 34 C.F.R. §104.35(c) each member who participates in the placement decision must be knowledgeable about the 
student, the meaning of the evaluation data, and/or accommodation and placement options. 
 
A.
Enter each team member’s name, and mark the applicable knowledge base.
 
 
Meaning of 
Accommodation 
Team Member 
Student 
Evaluation 
and Placement 
Data 
Options 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
B. Eligibility Determination 
 
Select
(1) Based on the above information, does the student have a physical and/or mental impairment?  _________ 
                                                                                                                                                                                   
Select
(2) If yes, does the impairment substantially limit at least one major life activity? __________  
(Yes, No, or N/A) 
      See State Rule 160‐4‐2‐.32, Determining Substantial Limitations for definition/guidance. 
 
 
IF THE ANSWER TO QUESTION (1) OR (2) IS ‘NO’, THEN THE STUDENT IS NOT ELIGIBLE FOR SECTION 504 
SERVICES. THE ELIGIBILITY PROCESS IS HALTED. PARENT SIGNS BELOW. 
 
 
“I have received a copy of Procedural Safeguards under Section 504.” _________________________________ 
                                                                                                                                                                       Parent signature 
 
 
Page 3 
Georgia Department of Education
Model Form | August 2018
                                                                                                                                                                                          
                                                                                    
                                                                                   Section 504 Eligibility Determination
 
 
 
IF THE ANSWERS TO QUESTIONS (1) AND (2) ARE ‘YES’, THEN THE STUDENT IS ELIGIBLE FOR SECTION 504 
SERVICES. PROCEED WITH DEVELOPMENT OF A 504 SUPPORT AND ACCOMMODATIONS PLAN FOR THE 
STUDENT. PARENT SIGNS BELOW. 
 
“I have received Notice of Rights of Students and Parents under Section 504.”  __________________________ 
                                                                                                                                                                                            Parent signature 
  
“I have received a copy of Procedural Safeguards under Section 504.” _________________________________ 
                                                                                                                                                                       Parent signature 
 
 
 
 
S
6
S
504
S
A
P
M
ECTION 
 
 
ECTION 
 
UPPORT AND 
CCOMMODATIONS 
LAN 
EETING
 
_____________________________________________________ has been found eligible for support and  
(Student Name)                                                                        
 
accommodations under
Section 504 of the Rehabilitation Act of 1973. The team must now schedule a meeting to 
 
develop a Section 504 Support and Accommodations Plan for your child. The members who participated in determining 
eligibility may or may not become members of your child’s 504 team. 
 
Your point of contact is: 
 
________________________________________________________ 
Name of LEA contact for this student’s Section 504 
 
________________________________________________________ 
LEA Contact number 
 
________________________________________________________ 
LEA Contact email address 
 
 
 
 
 
 
 
 
Page 4 
Georgia Department of Education
Model Form | August 2018
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