Manifestation Determination Review Documentation Form

Documents the team review of whether a student's conduct was a manifestation of their disability before discipline is imposed.

Submission Notice and Privacy Disclosure

• Purpose of Submission
• Privacy and Data Minimization Acknowledgment
• Consent to Record Review Findings

Student and Case Identification

• Student Full Name
• Student ID
• School Name
• Grade Level
• Case Number

Incident and Discipline Context

• Date of Incident
• Location of Incident
• Conduct Category
• Incident Summary
  Briefly describe what happened, using observable facts only.
• Proposed Discipline

Disability and Support Review

• Does the student have an IEP?
• Does the student have a Section 504 plan?
• Disability Category
• Relevant Accommodations, Supports, or Services
  List only supports relevant to the review, such as accommodations, behavior supports, or related services.
• Was a behavior intervention plan or behavior support plan in place?

Team Review and Determination

• Was the conduct caused by, or did it have a direct and substantial relationship to, the student's disability?
• Was the conduct the direct result of the school's failure to implement the IEP or Section 504 plan?
• Team Reasoning
  Summarize the facts, records reviewed, and rationale for the determination.
• Manifestation Determination Outcome

Follow-Up Actions, Sign-Off, and Audit Trail

• May the proposed discipline proceed?
• Required Follow-Up Actions
• Responsible Staff
  List the staff roles responsible for each follow-up action.
• Team Meeting Date
• Team Chair Signature