Manifestation Determination (25A)
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Student Name ,   Date of Birth   IEP Date  
 
   
   
 
  Manifestation Date Manifestation Date  
 
District of residence -   School  
 
   
 
Teacher   Grade   Gender   CSIS  
 
   
   
   
 
 
Parent/Guardian   Phone (H)   (W)   (C)  
 
   
   
   
 
Address   City   Zip  
 
   
   
 
 
Is the student an English Learner? Yes No   Primary Language -  
 
   
 
Date of current IEP   Date of last assessment  
 
   
 
 
Disability -  
 
 
 
  Current educational setting(s)  
 
 

 
  Description of behavior/actions of student resulting in this analysis  
 
 
  Disciplinary action taken / proposed   Date of decision of disciplinary action Date of decision of disciplinary action
 

 
In determining whether the student's behavior was a manifestation of his/her disability, the manifestation determination team considered the following in relation to the behavior subject to discipline (check applicable items):
 
  Teacher observations of the student. List:
 
  The student's IEP. Describe:
 
  Other relevant information supplied by the parents of the student. List:
 
  Other: List:
 

 
The Manifestation Determination team determined that, in relation to the behavior subject to disciplinary action:
 
  Yes No The conduct in question was caused by or had a direct and substantial relationship to the disability.
 
    Comments:
 
    or...
  Yes No The conduct in question was the direct result of a failure to implement the IEP.
 
    Comments: