Manifestation Determination (139a/b)

(This form prints as two separate pages)
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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
 
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:
 
 
  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:
 
      

 
Name   Position

 
Name   Position

 
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Name   Position

 
Name   Position

 
Name   Position