Section 504 Teacher Input Form

Student: _________________________________

Grade: __________

Date: ____________________

Teacher: _________________________________

Subject Taught: _______________________________________

Please answer the following questions to assist the 504 Team in determining eligibility for the above named student.

1. What strengths does this student exhibit in your class?

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2. What is the students current grade in your course/class?
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3. Please check all factors that may account for the students current grade if the student is performing below
expected grade level:
Missing Assignments
Failure to Participate
Excessive Absences/ Tardiness

Late Assignments
Inappropriate behavior

4. List assessment results that may also be affecting this students performance (i.e., MAP testing, classroom
assessments or tests, BOG testing, etc.).
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5. What challenges does this student exhibit in your class?
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6. Does this student have testing accommodations? Yes No If yes, please list:
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7. List modifications or accommodations that this student utilizes regularly in class.
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8. Are there any accommodations or modifications that the student regularly declines or refuses to use?
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9. Please list any accommodations or modifications that you have implemented on behalf of this student that is not
listed on his/her plan.
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10. Include any additional comments or information regarding the students progress.
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