Section 504 of the Rehabilitation Act of 1973
Student: School Year: 2019-2020
Is there a documented physical or mental impairment, which substantially limits a major life activity?
Does this student require accommodations designed to meet his/her needs as adequately as the needs of non-handicapped students? Yes No
Nature of Disability:
Data Sources Used for making 504 decision:
Check the major life activities that are substantially limited by the physical or mental impairment:
Description of how disability affects major life activity:
People responsible for accommodations:
Describe the appropriate placement:
How will the accommodations address the effects of the physical or mental impairment?
Accommodations for the Student:
Participants Names Title: