Templates › Forms › SEO page

Run: Manifestation Determination Review Documentation Form

This Manifestation Determination Review Documentation Form captures the team’s review of a student incident, the disability and support context, and the fina...

Fill this out, get a PDF emailed to you. No account required. Want to run it with your team and track results? Sign up free →

Submission Notice and Privacy Disclosure

Purpose of Submission

Privacy and Data Minimization Acknowledgment (required)

Yes No N/A

Consent to Record Review Findings (required)

Yes No N/A

Student and Case Identification

Student Full Name (required)

Student ID (required)

School Name (required)

Grade Level (required)

Case Number

Incident and Discipline Context

Date of Incident (required)

Location of Incident (required)

Conduct Category (required)

Incident Summary (required)

Briefly describe what happened, using observable facts only.

Proposed Discipline (required)

Disability and Support Review

Does the student have an IEP? (required)

Does the student have a Section 504 plan? (required)

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? (required)

Team Review and Determination

Was the conduct caused by, or did it have a direct and substantial relationship to, the student's disability? (required)

Was the conduct the direct result of the school's failure to implement the IEP or Section 504 plan? (required)

Team Reasoning (required)

Summarize the facts, records reviewed, and rationale for the determination.

Manifestation Determination Outcome (required)

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

May the proposed discipline proceed? (required)

Required Follow-Up Actions (required)

Responsible Staff (required)

List the staff roles responsible for each follow-up action.

Team Meeting Date (required)

Team Chair Signature (required)

Get your results

Enter your email — we'll send you a PDF of your filled-out template, plus the occasional MangoScoop newsletter (templates, workflow tips, product updates). Unsubscribe anytime — link is in every email.

Email (required)

Your name (optional)

Generated with MangoApps Templates — browse 250+ free