Manifestation Determination (139a/b)

(This form can generate more than one printed page)
 
  Name     Date of Birth   Date Date  
 

 
  Primary disability of student Primary disability of student   Current educational setting(s)  
     
 
  Date of most recent IEP Date of most recent IEP   Date of most recent triennial Date of most recent trennial   Case manager Case manager   (select)  
 
  Date of incident Date of incident   Dates of
suspension
 
 
  Date parent notified and given the Procedural Safeguards Date parent notified and given the Procedural Safeguards   Dates of
Manifestation Hearing
 
 

 
  District of Residence District of Residence   District of Service District of Service  
     
 
  School of Residence School of Residence   School of Attendance School of Attendance  
     
 
  If you cannot find the school in the drop-down list, you can try entering the school code and/or name below:  
   (select)    (select)  
 

 
    BSP   BIP  
  Was there a behavior plan in effect PRIOR to the misconduct?    
 
  If Yes should the behavior plan be revised?  
 
  Does the student need a functional assessment of behavior to develop a behavior intervention plan?  
 
  Date of functional assessment Date of functional assessment   Date behavior plan implemented Date behavior plan implemented  
 

 
  Describe the behavior necessitating a manifestation determination:  
 
 
  The LEA, parent, and the relevant members of the IEP team have reviewed all "relevant information in the student's file, including any teacher observations, and any relevant information provided by the parents." 20 USC 1415(k)(1)(E)(i); 34 CFR 300.530(e)(1).  
 
 
  Documents reviewed:  
  IEP Grades/Progress Cum. File Anecdotal records  
 
  Assessments Attendance records Behavior Plan(s) Parent information  
 
  Health Discipline records Observation Other   
 

 
  Review Summary:  
 
 
  Was the conduct in question caused by, or did it have a direct and substantial relationship to the student's disability?  
 
  Rationale:  
 
 
  Was the conduct the direct result of the local educational agency's failure to implement the IEP?  
 
  Rationale:  
 
 

 
  Team Recommendations/Next Steps  
 
  Disciplinary proceedings not recommended; IEP Team agrees behavior is a manifestation of the disability.  
    FAA and BIP required; or,  
    BIP review; modify as necessary to address the behavior  
 
  Proceed with disciplinary action; behavior not a manifestation of the disability.  
    Conduct was not caused by or did not have a direct and substantial relationship to, the student's disability  
    Conduct was not the direct result of the local education agency's failure to implement the IEP  
 
  Alternative placement needed.  
 
  Rationale:  
 
 

 

 
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