ࡱ> OQNc "jbjb&& (DDDx8*T~$.PD,R,,$ 3Z0 Student:  FORMTEXT      ,  FORMTEXT       Birth date:  FORMTEXT       Date:  FORMTEXT       (Last) (First) District of Residence:  FORMTEXT       School:  FORMTEXT       Teacher:  FORMTEXT       Grade:  FORMTEXT       Gender:  FORMCHECKBOX  M  FORMCHECKBOX  F CSIS:  FORMTEXT       Parent/Guardian:  FORMTEXT       Phone: (H)  FORMTEXT       (W)  FORMTEXT       (C)  FORMTEXT       Address:  FORMTEXT       City:  FORMTEXT       Zip:  FORMTEXT       Is the student limited in English proficiency?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Primary Language:  FORMTEXT       Date of Current IEP:  FORMTEXT       Date of last assessment:  FORMTEXT       Disability:  FORMTEXT       Current educational setting(s):  FORMTEXT       Description of behavior/actions of student resulting in this analysis:  FORMTEXT       Disciplinary action taken/proposed:  FORMTEXT       Date of decision of disciplinary action:  FORMTEXT       Upon determining whether the student s behavior was a manifestation of his/her disability, the manifestation determination team considered the following in relation to the behavior subject to discipline (check the applicable items):  FORMCHECKBOX  Evaluation and diagnostic results: List:  FORMTEXT        FORMCHECKBOX  Observations of the student. List:  FORMTEXT        FORMCHECKBOX  Student s IEP, services, and placement. Describe:  FORMTEXT        FORMCHECKBOX  Other relevant information. List:  FORMTEXT       The Manifestation Determination team determined that, in relation to the behavior subject to disciplinary action:  FORMCHECKBOX  Yes  FORMCHECKBOX  No The behavior was caused by or had a direct and substantial relationship to the disability. Comments:  FORMTEXT        FORMCHECKBOX  Yes  FORMCHECKBOX  No The behavior was the direct result of a failure to implement the IEP. Comments:  FORMTEXT       The Manifestation Determination team decided that the student s behavior:  FORMCHECKBOX  was a manifestation of his/her disability. (requires a  yes on any 1 of the above 2 items) Discipline proceeding may not occur at this time. Programming recommendations are:  FORMTEXT        FORMCHECKBOX  was not a manifestation of his/her disability. (requires a  no on both of the above 2 items) Proceed with disciplinary proceedings, all conditions have been met. (Behavior not a manifestation of students disability, student understood impact and consequences of behavior, student could control behavior, and services and supports were correct at time of incident.) Parent:  FORMCHECKBOX  agrees  FORMCHECKBOX  disagrees with the determination of the Manifestation Determination team. Comments:  FORMTEXT       Parent received copy of Procedural Safeguards (Parent Rights):  FORMCHECKBOX  Yes  FORMCHECKBOX  No Date:  FORMTEXT       Signatures: ______________________________________ Date:_____________ Parent ______________________________________ Date:_____________ Parent ______________________________________ ____________________________ Date:_____________ Title ______________________________________ ____________________________ Date:_____________ Title ______________________________________ ____________________________ Date:_____________ Title ______________________________________ ____________________________ Date:_____________ Title ______________________________________ ____________________________ Date:_____________ Title ______________________________________ ____________________________ Date:_____________ Title ______________________________________ ____________________________ Date:_____________ Title ______________________________________ ____________________________ Date:_____________ Title ______________________________________ ____________________________ Date:_____________ Title ______________________________________ ____________________________ Date:_____________ Title     Sonoma County Special Education Local Plan Area MANIFESTATION DETERMINATION FINDINGS SELPA 25 (two pages) Rev. 2/11 (*,68<>RTV`b.0DFHRzizX!jh%hnT5>*U!jhhL+hnT5>*U jhnT5>*UmHnHu!jhL+hnT5>*U hnT5>*jhnT5>*U!jth%hnT5>*U&jh%hnT5>*UmHnHu!jh%hnT5>*Uh%hnT5>*jh%hnT5>*UhnT" H J X Z n p Z\.0jl "gdnT""RTln8:<FHdfh~퉔~m!jh%hnT5>*Uj"hnTUjhnTUjhnTU!j:h%hnT5>*U!jh%hnT5>*U&jh%hnT5>*UmHnHu!jRh%hnT5>*Uh%hnT5>*hnTjh%hnT5>*U* " $ . 0 @ B V X Z d f v x     " ྭྜྋzi!jNh%hnT5>*U!jh%hnT5>*U!jfh%hnT5>*U!jh%hnT5>*U!j~h%hnT5>*Uh%hnT5>*hnT&jh%hnT5>*UmHnHujh%hnT5>*U!j h%hnT5>*U)" 6 8 : D F   0 2 F H J T V   $ & : ׿׿׿n׿!j h%hnT5>*U!j h%hnT5>*U!j h%hnT5>*UjhnTUj6hnTUjhnTUhnT&jh%hnT5>*UmHnHujh%hnT5>*U!jh%hnT5>*Uh%hnT5>*': < > H J F H \ ^ ` j l 24HJLVXྭྜྋȀyhWy jhnT5>*UmHnHu!jJ h>bhnT5>*U hnT5>*jhnT5>*U!j h%hnT5>*U!jb h%hnT5>*U!j h%hnT5>*Uh%hnT5>*hnT&jh%hnT5>*UmHnHujh%hnT5>*U!jz h%hnT5>*U"02NPRBDXZ\fhln"$@BD۬ѐ۬t۬ijxhnTU!jh%hnT5>*UjhnTU!jh%hnT5>*Uj hnTU&jh%hnT5>*UmHnHu!j4 h%hnT5>*Uh%hnT5>*jh%hnT5>*Uj hnTUjhnTUhnT)D& (*F|qjhnTU!jJh%hnT5>*UjhnTUh bhnT5j`hnTUjhnTU hnT5>* hnT5&jh%hnT5>*UmHnHu!jh%hnT5>*Uh%hnT5>*jh%hnT5>*UhnT*" "$&rtXCD^gdnT ^`gdnTgdnTFHJNRT  &8JL`bdnptvò͞۔ۄn͞^jhnThnT5U!jh%hnT5>*U hnT>*jhnThnT5UjhnT5U&jh%hnT5>*UmHnHu!jh%hnT5>*Uh%hnT5>*jh%hnT5>*U hnT5h bhnT5hnTjhnTUj2hnTU$BCDNOYZ  񴪙ynyycyXjhnT5>*UjRhnTUjhnTUjhnTUhnT&jh%hnT5>*UmHnHu!jhh%hnT5>*Uh%hnT5>*jh%hnT5>*U h%+KhnTh%+KhnT5jhnThnT5Uj|hnThnT5U hnT5jhnT5UDN "$<>$+LZ $ { E!S!!gdnT $:YZ# $ R!S!!!""" 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