Section 504 Manifestation Determination Student’s
Name: ___________________________
Date of Birth: _________________ Today’s Date: __________________
Parent(s) Name: _____________________________________________
District/School: _______________________________________________
Staff Member Completing this Form: ______________________________
1. Description of the student's disability: (review the relevant information in the student's file, including information from parents, any teacher observations, and the student's 504 plan)
2. Description of misconduct: (be as detailed as possible) NOTE: if the misconduct described above involves the use of drugs and/or alcohol, the student may disciplined in the same manner as a non-disabled student.
3. Based on this review, the 504 Team has determined that:
The conduct in question was caused by, or had a direct and substantial relationship to, the student’s disability.*
Yes No
The conduct in question was the direct result of the district’s failure to implement the student’s 504 Plan.*
Yes No
*If the members of the 504 team determine that the answer is YES to either of the above questions, the conduct shall be determined to be a manifestation of the student’s disability.
The conduct in question WAS a manifestation of the student’s disability.
The school may not exclude the student from instruction, may not suspend the student for more than 10 days, and may not expel the student, unless the conduct involved the use of drugs or alcohol. The team should review whether the student's eligibility and educational services remain appropriate.
The conduct in question WAS NOT a manifestation of the student’s disability.
The student may be disciplined in the same manner as a non-disabled student.
