NAME OF SCHOOL:

Date:	Student Name:	Grade:

Name of person making referral:

Relationship to student:

Name of school 504 Plan Coordinator:

*Section 504 is designed to meet the individual educational needs of a student with a disability as adequately as the needs of students without disabilities.

Identify the suspected physical or mental impairment(s) (i.e., thinking, concentrating, reading, learning, communicating, walking, standing, immune system, etc.):

Describe the suspected impact of the physical or mental impairment(s) checked above and note any observed difficulties resulting from the suspected physical or mental impairment(s):

Observed difficulties resulting from the suspected disability:

List prior successful/unsuccessful accommodations that have been made to address the suspected disability:

Is the student receiving passing grades in all subject areas?

☐ YES ☐ NO

If no, in what subject areas is the student currently failing? Please explain.

Are you concerned about the student’s attendance?

☐ YES ☐ NO

If yes, please explain:

Has the student been retained?

☐ YES ☐ NO

If yes, please explain:

Has the student received disciplinary action for inappropriate behavior?

☐ YES ☐ NO

If yes, please explain:

Is the student currently on a Health Care Plan for the suspected disability or does the student have an existing health condition?

☐ YES ☐ NO

Please explain:

Has the student ever been referred, evaluated and/or received special education services?

☐ YES ☐ NO

If yes, please explain:

_____________________________________	_______________

Signature of person making referral	Date