504 Initial Referral Form



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504 Initial Referral Form


Page 1 of 3

Submit completed form and supporting documents to the Building 504 Coordinator.


Student name:       DOB:      

School:       Grade:       ID#:      

Person completing this referral:      

Relationship to Student      

Date submitted:      

Supporting Documentation

Check all documents/reports included with Initial Referral


Medical

School



Psychological Evaluation



Report Card/Course History



Physician’s Report



Standardized Assessments (ITBS/ITED, Star)



Health History



General Education Interventions



Other:      



Work Samples

Home / Community



Curriculum-based assessments



Parent Input



Discipline Report



Home History



Attendance Report



Community Agency Report



Student Performance Review



Other:      



Other:      

Other









Observation Data









Other:     






Page 2 of 3

Section 504 Regulations define physical or mental impairment'' as (A) any physiological disorder or condition, cosmetic disfigurement, or anatomical loss affecting one or more of the following body systems: neurological; musculoskeletal; special sense organs; respiratory, including speech organs; cardiovascular; reproductive, digestive, genito-urinary; hemic and lymphatic; skin; and endocrine; or (B) any mental or psychological disorder, such as mental retardation, organic brain syndrome, emotional or mental illness, and specific learning disabilities
Based on the definition above, state the physical or mental impairment of concern. Provide available supporting documentation.      



Is impairment...

No

Yes - Provide detailed explanation

Note frequency, intensity and duration



Temporary (expected to last 6 months or less)?



     

Episodic or intermittent (not always present)?



     

In remission?




     

Related to cultural, economic or environmental issues?



     

Reduced by use of mitigating measures such as medication, physical devices or technology?



     

Page 3 of 3

Describe how the disability affects any Major Life Activity listed below

Major Life Activity (MLA)

  • Include specific examples.

  • Include comparison to how peers perform the same activity

  • Note differences when/if mitigating measures listed above are in effect

Seeing

     

Hearing

     

Breathing

     

Walking

     

Learning

     

Communicating

     

Thinking

     

Concentrating

     

Reading

     


Operation of major bodily function (ie: digestive or immune system)

     

Other

     

Additional Comments (use additional pages if necessary)



     


MCSD 504 Revised 3-10-10


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