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| Student's Full Name: ___________________________________________ | Birthdate: _______________ |
| Nature of the Student's Disability: ________________________________________________________________________ |
| Nature of the Behavior Subject to Disciplinary Action: _____________________________________________________ |
| |
| Determination of the Relationship of the Behavior of Concern to the Student's Disability |
| 1. In relationship to the behavior subject to disciplinary action |
| a. Did the IEP team review relevant information in the student's file and the student's IEP? q Yes q No |
| b. Did the IEP team review relevant information presented by the parents & teacher observations? q Yes q No |
| c. Did the IEP team determine that the conduct in question was caused by/or had a direct & substantial relationship to the child's disability? q Yes q No |
| d. Was the child's conduct a direct result of the district's failure to implement the IEP? q Yes q No |
| |
| 2. The behavior is a manifestation of the student's disability, if the IEP team indicated |
| a. "Yes" on item c or d of 1. above. | |
| |
| Conclusion: | |
| Based on the information considered, the IEP team determined that the behavior |
| q was q was not a manifestation of the student's disability. | |
| Date of Manifestation Determination Review: _______________ | |
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| Signature: _____________________________________________________ | Title: __________________________________ |
| Signature: _____________________________________________________ | Title: __________________________________ |
| Signature: _____________________________________________________ | Title: __________________________________ |
| Signature: _____________________________________________________ | Title: __________________________________ |
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