Manifestation Determination Local Forms - UCPS - Exceptional ...

Programs for Exceptional Children
Union County Public Schools
Monroe, North Carolina
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MANIFESTATION DETERMINATION WORKSHEET
Student:
DOB: _____/_____/_____
School: Grade: Area of Disability:
Under the Individuals with Disabilities Education Act of 2004, students with disabilities are entitled to a meeting called Manifestation
Determination. In other words, when a student with a disability is recommended for long term suspension, we have a suspension
review meeting (Manifestation Determination) to see if the conduct being considered is related to their disability.
‣ Sources of Information (check all that apply):
Assessment/evaluations (attach assessments and summaries)
Medical information, including diagnosis and medication (attach results)
Interviews conducted (attach summaries)
Direct observations (attach summaries)
Discipline reports for the current school year (attach)
Functional Behavioral Assessment (attach)
1. Is the student “in process” of being identified for exceptional children’s services?
( ) Yes ( ) No
2. Does the student have a history of services with the Exceptional Children’s Department?
( ) Yes ( ) No
Provide brief narrative:
3. Does the student have a history of disciplinary actions? (D­track attached) (attach calendar)
(a) Does the student have a current (1 year) behavior support plan (BIP) based on current (1 year) functional
behavioral assessment? If no, explain.
( ) Yes ( ) No
(b) Has there been a change in behavior over time (i.e., increase in frequency or duration of intensity)?
( ) Yes ( ) No
Explain:
(c) What is the history of behavioral interventions and what has proven effective?
4. Describe the incidents that led to recommended suspension.
(a) Administrator and/or school staff
(b) Student

Programs for Exceptional Children
Union County Public Schools
Monroe, North Carolina
Page 2 of 2
MANIFESTATION DETERMINATION WORKSHEET
5. Was the student told about and explained the consequences of the school policy regarding the conduct being considered?
( ) Yes ( ) No
Explain:
E. 1. Is the conduct being considered caused by or have a direct and substantial relationship to the disability?
( ) Yes ( ) No
2. Was the conduct a direct result of the LEA’s failure to implement the IEP. If yes, explain.
( ) Yes ( ) No
* If E1 or E2 are “yes”, the team must determine that the conduct was a manifestation of the disability.
OTHER INFORMATION THAT WILL BE CONSIDERED BY THE TEAM (ex. info from parent):
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Based on the above factors, is the conduct being considered a manifestation (or related to) the child’s disability?
NO. The student may be disciplined using procedures applicable to non­disabled students (except that under the IDEA,
educational services may not cease). Parents shall be informed of their procedural safeguards. A new functional behavioral
assessment and behavioral support plan should be completed or existing one(s) revised.
YES. Reevaluate the student’s IEP for appropriateness, including the current placement. A new functional behavioral
assessment and behavioral support plan should be completed or existing one(s) revised. The student may not be removed.
Committee Signatures Position Date
LEA Representative
Regular Education Teacher
Special Education Teacher
Parent
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
White copy – School Yellow Copy – EC Office Pink Copy – Parent
09/05/08