Manifestation Determination Local Forms - UCPS - Exceptional ...
Manifestation Determination Local Forms - UCPS - Exceptional ...
Manifestation Determination Local Forms - UCPS - Exceptional ...
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Programs for <strong>Exceptional</strong> Children<br />
Union County Public Schools<br />
Monroe, North Carolina<br />
Page 1 of 2<br />
MANIFESTATION DETERMINATION WORKSHEET<br />
Student:<br />
DOB: _____/_____/_____<br />
School: Grade: Area of Disability:<br />
Under the Individuals with Disabilities Education Act of 2004, students with disabilities are entitled to a meeting called <strong>Manifestation</strong><br />
<strong>Determination</strong>. In other words, when a student with a disability is recommended for long term suspension, we have a suspension<br />
review meeting (<strong>Manifestation</strong> <strong>Determination</strong>) to see if the conduct being considered is related to their disability.<br />
‣ Sources of Information (check all that apply):<br />
Assessment/evaluations (attach assessments and summaries)<br />
Medical information, including diagnosis and medication (attach results)<br />
Interviews conducted (attach summaries)<br />
Direct observations (attach summaries)<br />
Discipline reports for the current school year (attach)<br />
Functional Behavioral Assessment (attach)<br />
1. Is the student “in process” of being identified for exceptional children’s services?<br />
( ) Yes ( ) No<br />
2. Does the student have a history of services with the <strong>Exceptional</strong> Children’s Department?<br />
( ) Yes ( ) No<br />
Provide brief narrative:<br />
3. Does the student have a history of disciplinary actions? (Dtrack attached) (attach calendar)<br />
(a) Does the student have a current (1 year) behavior support plan (BIP) based on current (1 year) functional<br />
behavioral assessment? If no, explain.<br />
( ) Yes ( ) No<br />
(b) Has there been a change in behavior over time (i.e., increase in frequency or duration of intensity)?<br />
( ) Yes ( ) No<br />
Explain:<br />
(c) What is the history of behavioral interventions and what has proven effective?<br />
4. Describe the incidents that led to recommended suspension.<br />
(a) Administrator and/or school staff<br />
(b) Student
Programs for <strong>Exceptional</strong> Children<br />
Union County Public Schools<br />
Monroe, North Carolina<br />
Page 2 of 2<br />
MANIFESTATION DETERMINATION WORKSHEET<br />
5. Was the student told about and explained the consequences of the school policy regarding the conduct being considered?<br />
( ) Yes ( ) No<br />
Explain:<br />
E. 1. Is the conduct being considered caused by or have a direct and substantial relationship to the disability?<br />
( ) Yes ( ) No<br />
2. Was the conduct a direct result of the LEA’s failure to implement the IEP. If yes, explain.<br />
( ) Yes ( ) No<br />
* If E1 or E2 are “yes”, the team must determine that the conduct was a manifestation of the disability.<br />
OTHER INFORMATION THAT WILL BE CONSIDERED BY THE TEAM (ex. info from parent):<br />
____________________________________________________________________________________________________________<br />
____________________________________________________________________________________________________________<br />
Based on the above factors, is the conduct being considered a manifestation (or related to) the child’s disability?<br />
NO. The student may be disciplined using procedures applicable to nondisabled students (except that under the IDEA,<br />
educational services may not cease). Parents shall be informed of their procedural safeguards. A new functional behavioral<br />
assessment and behavioral support plan should be completed or existing one(s) revised.<br />
YES. Reevaluate the student’s IEP for appropriateness, including the current placement. A new functional behavioral<br />
assessment and behavioral support plan should be completed or existing one(s) revised. The student may not be removed.<br />
Committee Signatures Position Date<br />
LEA Representative<br />
Regular Education Teacher<br />
Special Education Teacher<br />
Parent<br />
____________________________________________________________________________________________________________<br />
____________________________________________________________________________________________________________<br />
____________________________________________________________________________________________________________<br />
White copy – School Yellow Copy – EC Office Pink Copy – Parent<br />
09/05/08
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