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Attachment #1 1.08 (06/95) LOCAL AGENCY 504 EVALUATION Section I - Agency Identification Name and Address of Local Agency: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Name and Address of WIC Clinic: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Date evaluation conducted: ____________________________________________________________________________ Name/title of person(s) conducting evaluation: ____________________________________________________________________________ Name/address of person(s) with a disability or organizations assisting in evaluation: ____________________________________________________________________________ ____________________________________________________________________________ Section II - Program Accessibility Are all services accessible to people with disabilities? ____________________________________________________________________________ In selecting alternative plans to make programs more accessible, has priority been given to methods that allow people with disabilities to participate in Program activities in the most integrated setting appropriate? ____________________________________________________________________________ Was the evaluation conducted with the assistance of people with disabilities or organizations representing people with disabilities? 1 of 5