S o u t h Wa s h i n g t o n C o u n t y S c h o o l s

Woodbury Middle School

1425 School Drive
Woodbury, MN 55125
Phone: 651-768-4500 Fax: 651-768-4567

SECTION 504 EVALUATION RESULTS AND REVIEW

Student Name:
School: Woodbury Middle School
Parent/Guardian Name:

DOB:
Grade:
Phone:

TYPE OF PROPOSED EVALUATION:

Initial Evaluation
Review/Reevaluation
DATE OF EVALUTION MEETING(S):

TEAM PARTICIPANTS:

PARTICIPANTS
SIGNATURE

NAME

TITLE

DATE

x
x
x
x
x
x
STATE THE REASON(S) THE STUDENT IS BEING EVALUATED UNDER SECTION 504 (DESCRIBE
THE NATURE OF THE CONCERN):

TYPES OF INFORMATION CONSIDERED DURING EVALUATION:

Review of information from parent/guardian

Review of information from physician/medical provider
Review of information from classroom teachers
Classroom observations
Interviews or rating scales
Cognitive testing
Academic achievement testing
Functional behavior assessment
Review of records (grades, work samples, etc.)
The WMS Wildcat Way

Respectful Responsible Participate Persevere

We are committed to igniting a passion for lifelong learning.
www.sowashco.k12.mn.us/wms

S o u t h Wa s h i n g t o n C o u n t y S c h o o l s
Woodbury Middle School
1425 School Drive
Woodbury, MN 55125
Phone: 651-768-4500 Fax: 651-768-4567

Other (specify) _________________________

The WMS Wildcat Way

Respectful Responsible Participate Persevere

We are committed to igniting a passion for lifelong learning.
www.sowashco.k12.mn.us/wms

S o u t h Wa s h i n g t o n C o u n t y S c h o o l s
Woodbury Middle School
1425 School Drive
Woodbury, MN 55125
Phone: 651-768-4500 Fax: 651-768-4567

GRADE UPDATES:

Trimester 1

Trimester 2

Current
(Trimester 3)

1A Phy Ed
1B Band
2 AVID
3/4 Algebra
4/5 Language Arts
6 Math Lab
7 Science
8 Social Studies
9 INSERT CLASS
STRENGTHS & AREAS OF NEEDED IMPROVEMENT INFO FROM TEACHERS
STRENGTHS
AREAS OF IMPROVEMENT

CONCERN AREAS: (based on information provided by # teachers)

ACADEMICS
ATTENDANCE
BEHAVIOR

The WMS Wildcat Way

Respectful Responsible Participate Persevere

We are committed to igniting a passion for lifelong learning.
www.sowashco.k12.mn.us/wms

S o u t h Wa s h i n g t o n C o u n t y S c h o o l s
Woodbury Middle School
1425 School Drive
Woodbury, MN 55125
Phone: 651-768-4500 Fax: 651-768-4567

ACCOMMODATIONS THAT HAVE ALREADY BEEN USED:

DETERMINATION OF ELGIBILITY UNDER SECTION 504

The WMS Wildcat Way

Respectful Responsible Participate Persevere

We are committed to igniting a passion for lifelong learning.
www.sowashco.k12.mn.us/wms

S o u t h Wa s h i n g t o n C o u n t y S c h o o l s
Woodbury Middle School
1425 School Drive
Woodbury, MN 55125
Phone: 651-768-4500 Fax: 651-768-4567

1. Does the student have a mental or physical impairment?

Yes
No
2. If the answer to #1 is yes, does the impairment limit one or more major life activities?
Yes
No
3. If the answer to #2 is yes, describe how the impairment limits one or more major life activities.
4. If the answer to #2 is yes, is the limitation substantial as compared to an average student?
Yes
No
Impact on Major Life Activities Compared to Average Student
Ineligible for 504
Eligible for 504
0
1
2
3
4
5
None
Minimal
Mild
Moderate
Substantial
Extreme
Breathing
Seeing
Hearing
Speaking
Walking
Mobility
Learning
Behavior
Social/
Emotional
Other

This student qualifies for a 504 Plan:

YES

NO

4. State why the team has determined that the impairment substantially limits, or does not substantially limit, a
major life activity.

5. If the answer to #4 is yes, the student is an individual with a disability and is entitled to protections under
Section 504. Proceed to consideration of Section 504 Accommodation Plan.

The WMS Wildcat Way

Respectful Responsible Participate Persevere

We are committed to igniting a passion for lifelong learning.
www.sowashco.k12.mn.us/wms