Student’s Full Name_________/ Date_______
School_________/ Date ofBirth _______
Parent(s)/Guardian(s)_________/ Grade______
Address______/ WVEIS#______
City/State ______________ / Telephone______
Section 1: If the student meets one or more of the following criteria, proceed to Section 2.
___ at the time of the incident, the student had a disability (IDEA or 504).
___ the student is in the multidisciplinary evaluation process.
___ the parent(s) has/have expressed in writing to supervisory personnel that the student may be in need of
special education and related services.
___ the parent(s) has/have requested in writing a multidisciplinary evaluation.
___ the student’s teacher or other district personnel have expressed concerns about a pattern of behavior to the district’s director of special education or other district supervisory personnel.
Section 2: The student’s disciplinary removal on ______is a disciplinary change of placement if the criteria in either A OR B are met: Date(s)- ______a removal for more than 10 consecutive school days.
- ______a series of removals that constitutes a pattern as established by meeting ALL three criteria:
- More than 10 cumulative school days; AND
- Similarity of behaviors; AND
- Length of each removal and proximity of removals to one another.
Document the date provided: ______and the method provided: ___ hand-delivered ___ emailed/faxed.
Proceed to Section 3, as a Manifestation Determination is required at this time.
***
If neither A nor B is met, a disciplinary change of placement has not occurred.
Proceed to Section 5: Consultation,as a Manifestation Determination is NOT APPLICABLE at this time.
Section 3: A Manifestation Determination was conducted on ______(within 10 school days) and the following documentation was reviewed by the team: Date
__ Incident report __ IEP/504 Plan __ Teacher observation(s) __ Attendance report ___ Parent information __ FBA/BIP
__ Discipline record __ Evaluation information __ Student schedule ___ Progress reports __Other______After reviewing the above documentation, the team must respond to the following statements:
___Yes ___No The conduct in question was caused by, or had a direct and substantial relationship to the student’s disability.
___Yes ___ No The conduct in question was a direct result of the district’s failure to implement the IEP.
If Yes to either statement, the conduct in question is a manifestation of the student’s disability and the team must: 1) conduct a FBA and develop a BIP, if one has not been completed; or 2) review the existing BIP and revise as needed to address the current behavior(s); and 3)return the student to the placement from which the student was removed, unless the parent and the district agree to a change of placement as determined by the IEP Team. If No, refer to Policy 2419, Chapter 7, Section 2.B.
Section 4: Manifestation Determination: Relevant IEP Team members as determined by the district and parent.
Signature: ______Position: ______
Signature: ______Position: ______
Signature: ______Position: ______
Signature: ______Position: ______
Section 5: Actions When Not a Change of Placement: Document that school personnel have consulted with at least one of the student’s teachers to determine the extent to which services are needed to enable the student to continue to participate in the general education curriculum, although in another setting, and to progress toward meeting the goals set out in the student’s IEP.
Extent of Services: ______
______Initials: Administrator ______Teacher______
DISCIPLINARY ACTION REVIEW FORM
ITEM / CLARIFICATIONS/INSTRUCTIONSThis form must be used to document that the disciplinary procedures outlined in Policy 2419, Chapter 7, have been followed for the student. This form may be completed on two separate dates (the same day the removal occurs and the date of the manifestation determination meeting).
Heading / Demographics / Complete ALL fields and attach a brief summary of the incident (e.g., WVEIS discipline entry, Notice of Suspension, anecdotal record, etc.)
1 / Student Eligibility / Select any of the five statements that apply to the student at the time of the proposed removal. If none apply, STOP. This form is not applicable.
2 / Change of Placement / Enter the date(s) of the current proposed removal which, when implemented, will exceed 10 consecutive or 10 cumulative days. Select A if the removal is for more than 10 consecutive school days. Select B if the removal constitutes a pattern as described in the criteria under B. In the box to the right, enter the total number of days the student has been removed to date.
Note: If the criteria in Section A or all criteria in Section B are met, a disciplinary change of placement has occurred. Document all 3 items are being provided to the parent on the same day the removal occurs. Document the date and method by which the items are provided. Proceed to Section 3.
Note: If neither criteria in Sections A nor B are met, a disciplinary change of placement has not occurred. Proceed to Section 5.
3 / Manifestation Determination / Document the date on which the manifestation determination is conducted (must be within 10 school days of any decision to change placement). Indicate by checkmark all relevant documentation reviewed by the appropriate team (i.e., IEP, 504, SAT).
Respond to each of the two statements. If the response to either statement is YES, the conduct in question is a manifestation of the student’s disability and the team mustfollow the procedures outlined in Policy 2419, Chapter 7, Section 2.A, as specified on the form.
If the response to both statements is NO, the conduct in question is not a manifestation of the student’s disability, and the team must follow these procedures outlined in Policy 2419, Chapter 7, Section 2.B:
1.Determine appropriate disciplinary action, which may include relevant disciplinary procedures applicable to students without disabilities;
2.Convene IEP Team to develop an IEP that specifies the educational services to be provided to enable the student to continue to participate in the general education curriculum, although in another setting, and to progress toward meeting the goals set out in the student’s IEP; and
3.Provide, as appropriate, a functional behavioral assessment, and behavior intervention services and modifications that are designed to address the behavior violation so that it does not recur.
4 / Manifestation Determination Members / Each member of the Manifestation Determination Team must sign and document his/her position.
5 / Actions When Not a Disciplinary Change of Placement / When the disciplinary removal is determined NOT to be a disciplinary change of placement, school personnel in consultation with at least one of the student’s teachers, must determine and document the extent of the services, if any, that are needed to enable the student to continue to participate in the general education curriculum, although in another setting, and to progress toward meeting the goals set out in the student’s IEP. The administrator and teacher making the determination must initial where indicated.
Use the Disciplinary Action Review Form only when disciplinary removals exceed 10 cumulative or 10 consecutive days and each time thereafter. Attach a brief incident summary, same-day written notice of suspension and PWN to this form.
DISCIPLINARY ACTION REVIEW FORM
______County
Student’s Full Name________/ Date_______School________/ Date ofBirth _______
Parent(s)/Guardian(s)_________/ Grade______
Address______/ WVEIS#_______
City/State ______/ Telephone_______
Section 1: If the student meets one or more of the following criteria, proceed to Section 2.
___ at the time of the incident, the student had a disability (IDEA or 504).
___ the student is in the multidisciplinary evaluation process.
___ the parent(s) has/have expressed in writing to supervisory personnel that the student may be in need of
special education and related services.
___ the parent(s) has/have requested in writing a multidisciplinary evaluation.
___ the student’s teacher or other district personnel have expressed concerns about a pattern of behavior to the district’s director of special education or other district supervisory personnel.
Section 2: The student’s disciplinary removal on ______is a disciplinary change of placement if the criteria in either A OR B are met: Date(s)- ______a removal for more than 10 consecutive school days.
- ______a series of removals that constitutes a pattern as established by meeting ALL three criteria:
- More than 10 cumulative school days; AND
- Similarity of behaviors; AND
- Length of each removal and proximity of removals to one another.
Document the date provided: ______and the method provided: ___ hand-delivered ___ emailed/faxed.
Proceed to Section 3, as a Manifestation Determination is required at this time.
***
If neither A nor B is met, a disciplinary change of placement has not occurred.
Proceed to Section 5: Consultation,as a Manifestation Determination is NOT APPLICABLE at this time.
Section 3: A Manifestation Determination was conducted on ______(within 10 school days of the removal) and the following documentation was reviewed by the team: Date
__ Incident report __ IEP/504 Plan __ Teacher observation(s) __ Attendance report ___ Parent information __ FBA/BIP
__ Discipline record __ Evaluation information __ Student schedule ___ Progress reports __Other______After reviewing the above documentation, the team must respond to the following statements:
___Yes ___No The conduct in question was caused by, or had a direct and substantial relationship to the student’s disability.
___Yes ___ No The conduct in question was a direct result of the district’s failure to implement the IEP.
If Yes to either statement, the conduct is a manifestation of the student’s disability and the team must: 1) conduct a FBA and develop a BIP, if one has not been completed; or 2) review the existing BIP and revise as needed to address the current behavior(s); and 3)return the student to the placement from which the student was removed, unless the parent and the district agree to a change of placement as determined by the IEP Team. If No, refer to Policy 2419, Chapter 7, Section 2.B.
Section 4: Manifestation Determination: Relevant IEP Team members as determined by the district and parent.
Signature: ______Position: ______
Signature: ______Position: ______
Signature: ______Position: ______
Signature: ______Position: ______
Section 5: Actions When Removals are not a Change of Placement: Document that school personnel have consulted with at least one of the student’s teachers to determine the extent to which services are needed to enable the student to continue to participate in the general education curriculum, although in another setting, and to progress toward meeting the goals set out in the student’s IEP.
Extent of Services: ______
______Initials: Administrator ______Teacher______
West Virginia Department of Education
July 2013