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Name:_______________________________________ Section 504 Evaluation Date:___________________




I. Date of SAT meeting:______________ Reason for Referral: (Information on 300R): ____Reading


____Handwriting Problems ____Behavior Problems

____Hearing/Vision Problems

____Motor Problems

____Other: Specify:___________________

(SAT meeting is not required for 3 year reevaluation.) Type of Evaluation:


Date of Parent Consent:_________________


Date of Parent Notice:__________________

Date Parent Notified of this Section 504 Determination meeting:_____________________

II. Evaluation Data Considered from a Variety of Sources: A copy of ALL evaluation data must be filed in the student’s Section 504 folder. ____Bulletin 1508 Evaluation (within 3 years) ____Dyslexia checklist & assessment* ____Private Evaluation (within 3 years) ____Dysgraphia checklist ____Medical Evaluation/Diagnosis (within 1 year) ____ADD/ADHD checklist ____Standardized Test Results ____Dyscalculia checklist ____Student work/input ____Social/Emotional checklist ____Parent Input ____Discipline records ____RTI/Early Intervening Data results ____Attendance record ____Teacher Input/Observations specific to the identified disability ____Other________________________________________________________________________________ *Refer to the district’s Dyslexia Handbook and Forms AND complete the Dyslexia Determination of Eligibility form. Additional comments:________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Form 4a 6/12

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ORLEANS PARISH SCHOOL BOARD SECTION 504 EVALUATION Name:______________________________________


III. Determination of Eligibility: 1. Does the student have a physical or mental impairment(s)?



Specify the mental or physical impairment(s):__Characteristics of__________________________________ _________________________________________________________________________________________ *An Individual Health Plan (IHP) MUST be filled out by the nurse and Form 12 must be completed if the student has a medical disability. If the disability is Dyslexia, then the student is recommended to participate in a Multisensory Structured Language Program (MSLP). Refer to Bulletin 1903.

2. What major life activity(ies) is/are affected by this condition and to what degree? Place an “x� in the appropriate space to indicate the specific degree that the impairment limits the major life activity: -Committee focuses and emphasizes the major life activity as a whole (e.g., learning) not a particular class (e.g. geometry). -Discount from the analysis sub-par performance due to other factors such as normal moods, lack of motivation and the immediate situation or environment. -Use the average student in the general population as the frame of reference for the purpose of comparison. Life Activities





Self Care Walking Seeing Hearing Breathing Learning Working Speaking Manual Tasks (Other) The impairment(s) must substantially/extensively limit the indicated major life activity to meet Section 504 eligibility requirements. Form 4a 6/12

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ORLEANS PARISH SCHOOL BOARD SECTION 504 EVALUATION Name:______________________________________


Results of the Section 504 Evaluation: INITIAL EVALUATION ______Student has a physical or mental impairment which substantially limits one or more major life activities. Regular classroom accommodations will be identified on an Individual Accommodation Plan (IAP). ______Student is eligible under section 504; however, needs no accommodations at this time. An IAP is completed, signed by the committee and reviewed annually. ______ Student is not eligible under Section 504. REEVALUATION ______ Student continues to be eligible under Section 504 and will receive an updated IAP according to the reevaluation. ______Student continues to be eligible under section 504; however, needs no accommodations at this time. An IAP is completed, signed by committee and reviewed annually. ______ Student is no longer eligible under Section 504 according to the reevaluation. An annual review is no longer needed. The student may be reconsidered for eligibility at any time through the SAT process.

We certify that this report represents the best, integrated description of this student at this time. The evaluation meets the criteria for eligibility and required evaluation procedures for the disabling condition(s) listed above. It was determined that the following factors did not interfere with the reliability of the evaluation data for the total evaluation process: evaluation conditions, rapport, motivation, length of examination, communication, race, or sex.

Signatures of SATeam/504 Team Members participating in the Section 504 Disability Evaluation* _____________________________ _____________________________ ____________________________** Section 504 Chairperson Referring Teacher Parent (received Rights & Grievance Procedures)

____________________________ Principal

_____________________________ ____________________________ Additional Person Knowledgeable Additional Person Knowledgeable of Student and/or Disability of Student and/or Disability

*The Section 504 Committee must consist of a minimum of three members knowledgeable of the student and/or the disability. **If the parent is not in attendance, then Form 5 must be signed by the parent. Copy to parent, 504 district office, original in student’s 504 folder Form 4a 6/12

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