Manifestation Determination Form
For Students with Section 504 or Suspected Disabilities
Student Name: / DOB: / Parkway ID #:
Parkway School: / Date of Meeting:
Names of Participants:
Date & Description of Behavior Infraction:
(Attach additional information, such as applicable sections from the discipline packet, as necessary)
Nature of Section 504 / Suspected Disability (describe &/or attach information/description):
Review all relevant information in the student’s file (e.g., evaluation/diagnostic results, concerns which led to the suspicion of a disability, interventions/accommodations), information provided by the parents, observations.
Sources of information for the determination (check all that apply):
School evaluation(s) / Interventions/support plan
Private evaluation(s) / Functional assessment
Student education record / Information from parent(s)
Student interview / Private information
Other:
DETERMINE IF:
A. / “the conduct in question was caused by, or had a direct and substantial relationship to” the student’s Section 504 disability or suspected disability
YES / NO / CANNOT BE DETERMINED
B. / “the conduct in question was the direct result of the local educational agency’s failure to implement” the Section 504 Individualized Accommodation Plan (IAP) or the intervention plan developed to address the suspected disability
YES / NO / CANNOT BE DETERMINED
If BOTH A. AND B. are answered as NO, the conduct is NOT a MANIFESTATION of the Section 504 or suspected disability. The disciplinary procedures applicable to children without disability may be applied to the student in the same manner and for the same duration in which the procedures would be applied to students without disabilities.
If EITHER A. OR B. is answered as YES, the conduct shall be determined to be a MANIFESTATION of the Section 504 or suspected disability. The IAP/IEP-like team is to address the student’s behavior by conducting a functional behavioral assessment and providing interventions, supports, and services.
If EITHER A. OR B. are answered as CANNOT BE DETERMINED, the student is to be treated as if the behavior is a manifestation of the disability and provided with appropriate procedural safeguards.
Comments/Other relevant factors:
*NOTE: Provide parent/guardian/majority age student with appropriate procedural safeguards
PSD – August 2009