Section 504/ADA MANIFESTATION DETERMINATION REVIEW

Date: ______

Student: ______/ Date of Birth: ______
Parent: ______/ Phone No: ______
Address: ______/ Grade: ______
School: ______/ 504 Manager: ______
Referred by: ______/ Current 504 Plan date: ______
Impairment for which the student has a Section 504 plan in place:
Team present for review: ______, ______, ______, ______

Issue:

Describe the specific conduct/behavior for which the student is being considered for disciplinary action and interventions attempted/steps taken to data. Include dates and relevant circumstances.* ______

*Under Section 504, the student is notentitled to a manifestation determination ifthe student is currently engaging in the illegal use of drugs. In such instances, the student may be disciplined in the same manner as an unimpaired student would be disciplined.

Review:

Sources of information considered (check all that were considered; sources not checked will be considered as“not applicable” to this determination):

Assessment/diagnostic data / Interviews conducted
Records review, including the student’s current Section 504 plan / Functional behavioral assessment
Direct observations of the student / Behavioral support plan

Consideration:

Please consider the following questions as the team discusses the specific conduct in relationship to the student’s Section 504 impairment and the review of the data indicated above:

1. Did the student’s impairment impinge on his or her ability to understand the impact and consequences of the behavior subject to disciplinary action? Yes No

2. Did the student’s impairment impinge on his or her ability to control the behavior subject to disciplinary action? Yes No

If the answer to either or both of the above questions is “Yes”, it must be determined that the behavior is a manifestation of the student’s impairment.

Determination:

Manifestation determination: Based on the answers to the above question the team has determined that the conduct
IS / IS NOT a manifestation of his/her impairment.

Further action required:

If the team has determined that the conduct described above IS a manifestation of the student’s impairment, the recommendation to long-term suspend, expel, or to impose any other disciplinary change of placement shall be withdrawn. The section 504 team should then make any changes to the student’s Section 504 Plan that it deems appropriate. (Use the “504 Regular Education InterventionPlan” form.)

If the team has determined that the conduct described above IS NOT a manifestation of the student’s impairment, the student may be disciplined in the same manner as an unimpaired student. No educational services need to be provided to the student other than those provided to unimpaired students.

Form 3300-F2 February 22, 2005