Student Sname

(INSERTSCHOOLDISTRICTNAME)MANIFESTATIONDETERMINATIONFORSECTION504STUDENTS

A.Identifyinginformation:

Student’sName:_

DateofMeeting:

DateofBirth:

B.ConferenceParticipants:

C.Teamreviewanddetermination:

1.Whatisthemisconductforwhichdisciplinaryactionhasbeentakenorisbeingconsidered?

2.Theteamhasconsideredandreviewedthefollowingrelevantstudentinformationintermsofthemisconductsubjecttodisciplinaryaction:

Evaluation,diagnosticresultsorotherrelevantinformation,including

thestudentsmostrecentSection504evaluationandplanYESNOIstherea behaviorintervention planaspart ofthestudent’s504plan? YES NO

3.Indeterminingifthemisconductwasamanifestationofhis/herdisability,theSection504teammustdeterminethefollowing:

(a)Ifthemisconductinquestionwascausedby,orhadadirectandsubstantialrelationshipto,thechild’sdisability; YES NO or

(b)IfthemisconductinquestionwasthedirectresultoftheDistrict’sfailuretoimplementtheSection504Plan YES NO

FormJ10/11

4.Iftheteamdeterminesthemisconductwasnotamanifestationofthechild’sdisability,thentheDistrict’sregulardisciplinaryprocedureswillapply.

5.Iftheteamdeterminesthatthemisconductwasamanifestationofthechild’sdisability:

(a)TheteammustconductaFunctionalBehavioralAssessmentandimplementabehaviorinterventionplan(BIP)ifthishasnotalreadybeendonepriortothecurrentmisconduct;

(b)IfaBIPhasalreadybeendeveloped,reviewandmodifyit,asnecessary,toaddressthemisconductinquestion;and

(c)Theteammustreviewthestudent’scurrent504planandeducationalplacementtodetermineifitremainsappropriate.Iftheteam believesthatasignificantchangeinplacementmaybenecessary,theteammustinitiateareevaluationofthestudent.

SECTON504FUNCTIONALBEHAVIORALASSESSMENT

Student
Grade / Date
Participants/Titles
Describethebehaviorofconcern
Whatstrategieshaveyoutriedtoaddressthebehavior?
Describethetriggersofthestudent’sbehavior
Howlongand/orhowoftenhasthisbehaviorbeenoccurring?
Doesthebehavioroccuronlyduringcertainsubjectsorsettings,and/ortimes;identify:
Whataretheconsequenceswhenthebehavioroccurs?
Hypothesisofthebehavior:

(INSERTSCHOOLDISTRICTNAME)

SECTION504BEHAVIORINTERVENTIONPLAN

Afunctionalassessment of behavior mustbecompletedandattachedpriorto developingaBehavior InterventionPlan

CompletewhentheSection504teamhasdeterminedaBehaviorInterventionPlanisneeded.

Student: / Grade: / Date:
TargetBehavior(s): / Intervention(s)tobeImplemented: / Procedure/scheduleforevaluatingeffectivenessandpersonresponsible: