Manifestation Determination Findings (a)

 
Student ,   Birthdate   IEP date  
 
   
   
 
 
District of residence -   School  
 
   
 
 
Teacher   Grade   Gender   CSIS  
 
   
   
   
 
 
Parent/Guardian   Phone (H)   (W)   (C)  
 
   
   
   
 
 
Address     City   Zip  
 
   
   
 
 
Is the student limited in English proficiency? 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 Pick a date
 

 
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)
 
  Evaluation and diagnostic results. List:
 
  Observations of the student. List:
 
  Student's IEP, services, and placement. Describe:
 
  Other relevant information. List:
 

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