"Local School System Manifestation Determination Form" - Georgia (United States)

Local School System Manifestation Determination Form is a legal document that was released by the Georgia Department of Education - a government authority operating within Georgia (United States).

Form Details:

  • Released on July 1, 2007;
  • The latest edition currently provided by the Georgia Department of Education;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Georgia Department of Education.

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Download "Local School System Manifestation Determination Form" - Georgia (United States)

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Local School System
Manifestation Determination Form
Student Name:_______________________
Date:__________________
THIS MANIFESTATION DETERMINATION MUST OCCUR WITHIN 10 SCHOOL DAYS OF ANY DECISION TO CHANGE THE
PLACEMENT OF A CHILD WITH A DISABILITY DUE TO A VIOLATION OF THE CODE OF CONDUCT.
The manifestation
determination review is conducted by child's parent and the relevant members of the child's IEP Team, as determined by the parent
and the school system. (NOTE: No manifestation determination review is required when a child is removed from his current placement
for NOT MORE THAN 10 SCHOOL DAYS to an interim alternative educational setting (IAES), another setting or via suspension, and
for additional removals of not more than 10 cumulative days in that same school year for separate incidents of misconduct, as long as
those removals do not constitute a pattern. Schools may make such short-term removals for violations of a code of student conduct to
the extent that such alternative settings are also applied to students without disabilities. In addition, schools may remove a student to
an IAES for not more than 45 school days without regard to whether the behavior is determined to be a manifestation of the child's
disability in cases where a child carries or possesses a weapon to or at school, on school premises or at a school function; knowingly
possesses or uses illegal drugs, or sells or solicits the sale of a controlled substance, while at school, on school premises, or at a
school function; has inflicted serious bodily injury upon another person while at school, on school premises, or at a school function.)
I. Description of the behavior incident that violated the code of conduct:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
II. Review of relevant information:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
___ IEP
___Any teacher observations
___Relevant information provided by parent(s)
___Other: _______________________________________________________________________________________
Georgia Department of Education
Model Form July 2007 Page 1 of 2
Local School System
Manifestation Determination Form
Student Name:_______________________
Date:__________________
THIS MANIFESTATION DETERMINATION MUST OCCUR WITHIN 10 SCHOOL DAYS OF ANY DECISION TO CHANGE THE
PLACEMENT OF A CHILD WITH A DISABILITY DUE TO A VIOLATION OF THE CODE OF CONDUCT.
The manifestation
determination review is conducted by child's parent and the relevant members of the child's IEP Team, as determined by the parent
and the school system. (NOTE: No manifestation determination review is required when a child is removed from his current placement
for NOT MORE THAN 10 SCHOOL DAYS to an interim alternative educational setting (IAES), another setting or via suspension, and
for additional removals of not more than 10 cumulative days in that same school year for separate incidents of misconduct, as long as
those removals do not constitute a pattern. Schools may make such short-term removals for violations of a code of student conduct to
the extent that such alternative settings are also applied to students without disabilities. In addition, schools may remove a student to
an IAES for not more than 45 school days without regard to whether the behavior is determined to be a manifestation of the child's
disability in cases where a child carries or possesses a weapon to or at school, on school premises or at a school function; knowingly
possesses or uses illegal drugs, or sells or solicits the sale of a controlled substance, while at school, on school premises, or at a
school function; has inflicted serious bodily injury upon another person while at school, on school premises, or at a school function.)
I. Description of the behavior incident that violated the code of conduct:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
II. Review of relevant information:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
___ IEP
___Any teacher observations
___Relevant information provided by parent(s)
___Other: _______________________________________________________________________________________
Georgia Department of Education
Model Form July 2007 Page 1 of 2
Local School System
Manifestation Determination Form
III. Manifestation Determination
a) Was the conduct in question caused by or does it have a direct and substantial
relationship to the child’s disability? _______
b) Is the conduct in question a direct result of the system’s failure to implement the
child’s IEP? _______
If the answer to either question III.(a) or III.(b) is YES, the conduct IS a manifestation of the child’s disability and
the child must be returned to the placement from which he was removed, unless: (1) incident involves weapons or
drug possession or infliction of serious bodily injury; or (2) the parent and the district agree to a change of
placement as part of the modification of the student’s behavioral intervention plan.
If the behavior was a manifestation of the disability, the following must be considered:
Has a functional behavioral assessment been conducted?
If NOT, one must be conducted and a behavioral intervention plan must be developed and implemented.
If a behavioral intervention plan been developed and implemented, what revisions are necessary to
prevent the behavior from occurring again?
If the answer to both of the above questions is NO, then the conduct is not a manifestation of the child’s
disability. The relevant disciplinary procedures applicable to children without disabilities may be applied in the
same manner to the child with a disability. The school system's FAPE obligations continue when the resulting
change of placement exceeds 10 school days, except that FAPE may be provided in an interim alternative
educational setting. The FAPE-related services must enable the child to continue to participate in the general
education curriculum, although in another setting, and to progress toward meeting the goals set out in the child's
IEP.
If the behavior was not a manifestation, the need for a functional behavioral assessment and a behavioral
intervention plan should be considered to prevent the behavior from recurring.
Team Members – The Team must consist of the parent and relevant members of the IEP Team as determined by
the system and the parent.
Name & Title
Name & Title
________________________________
______________________________________
________________________________
______________________________________
________________________________
______________________________________
Georgia Department of Education
Model Form July 2007 Page 2 of 2
Page of 2