Section504

MANIFESTATIONDETERMINATIONSUMMARY

(considerationofexpulsion,revocationofIDAorremovalfromcurrentplacementformorethan10daysinthesameschoolyear)

Student:DateofBirth:School:

CurrentEducationalPlacement:

AllegedBehaviorResultinginthisAssessment:

Dateofincident:Today’sdate:

DisabilityofStudent:

Assessmentteammembers(mustincludeLEArepresentative,parent,andrelevantmembersofthe504teamasdeterminedbyparentandLEA):

Inaccordancewith34codeofFederalRegulations,Part104this504Teammeetingisbeingconvenedtoreviewtherelationshipoftheabovenamedstudent’sdisabilityandthebehaviorsubjecttodisciplinaryaction.

Teamhasreviewedthefollowing(checktodocumentconsideration):

□Thestudent’s504Plan

□Teacherobservations

□Relevantparentinformation

□Relevantinformationinthestudent’sfile(behaviorplans,grades,STARScores,psychologicalassessments,etc.,asappropriate)

Afterreviewingtheaboveinformation,the504Teamhasmadethefollowingdeterminationsinrelationshiptothebehaviorsubjectodisciplinaryaction:

1.Wastheconductinquestioncausedby,ordidithaveadirectandsubstantialrelationshipto,thestudent’sdisability?

□Yes□No.Pleaseexplain:

2.WastheconductinquestionthedirectresultoftheLEA’sfailuretoimplementthe504Plan?

□Yes□No.Pleaseexplain?

IftheLEA,theparent,andrelevantmembersofthe504TeamdeterminethatEITHERoftheaboveconditionsexist,theconductmustbedeterminedtobeamanifestationofthestudent’sdisability.

ActionsTaken

Section504

MANIFESTATIONDETERMINATIONSUMMARY

3.Didthe504teamfindthattheconductwasamanifestationofthedisability?

□Yes(go tonumber4)□No(goto number5)

4.IftheteamcheckedYES,thenthe504Teammustdothefollowing(theteammustchooseeitherAorB,thenchooseeitherCoD).

A. □ConductaFunctionalBehavioralAssessment*andimplementabehavioralinterventionplanforthestudentifnonehadbeendevelopedbeforetheincident;OR

B □Review theexistingbehavioralinterventionplanandmodifyit,asnecessary,toaddressthebehavior(attachbehaviorplan)

C.□Returnthechildtotheplacementfromwhichthechildwasremoved;OR

D.□MovethechildtoanalternativeplacementifbothparentandLEAagreeaspartofthebehavioralinterventionplan.

5IftheteamcheckedNO(foundthattheconductwasNOTamanifestationofthedisability),allrelevantdisciplinaryactionsmaybeapplied(EducationCode48000following)andthefollowingactionsmustbetaken:

  • Thechildshallcontinuetoreceiveeducationalservices,soastoenablethechildtocontinuetoparticipateinthegeneraleducationcurriculum,althoughinanothersetting,andtoprogresstowardmeetingthegoalssetoutinthechild’s504Plan
  • Thechildmustreceive,asappropriate,afunctionalbehavioralassessment,behavioralinterventionservicesandmodifications,thataredesignedtoaddressthebehaviorviolationsothatitdoesnotrecur.

6.Theparentswerenotifiednolaterthanthedateonwhichthedecisionwasmadetotakedisciplinaryactions.Date:

7.Theparentsweregiventheproceduralsafeguardsnotice.Date:504TeamDiscussionNotes:

Signatures(indicatesattendanceatmeetingonly):

Parent:LEA Representative: 504teammember: 504 team member: 504teammember: 504 team member: 504teammember: 504teammember: