Form Sts 009 - Manifestation Determination For Students Eligible For Accommodations Under Section 504
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1The School Board of Saint Lucie County
Manifestation Determination
for Students Eligible for Accommodations under Section 504
Today’s Date ___________
DEMOGRAPHIC INFORMATION
Student Name:
DOB: ____________
Gender:
Race:
Language:
Student ID#:
Current School:
Grade:
Section 504 Condition (list all impairments or conditions):
Number of Cumulative Suspension days to date for this school year:
Description of the infraction or misconduct:
Proposed Disciplinary action which constitutes a change of placement:
Is this consistent with the disciplinary action proposed for students without disabilities? (circle one) Yes
No
THE FOLLOWING SOURCES OF INFORMATION HAVE BEEN REVIEWED
O Infraction for which suspension has been recommended
O Parental Information
O Account of incident
O Cumulative Folder
O Discipline History
O Observation
O Behavioral Intervention Plan (BIP)
O Evaluation and Diagnostic results
O 504 Accommodation Plan
O Other relevant information:
Under Section 504, a student is not entitled to procedural protections if the student’s misconduct involves the use of illegal drugs or alcohol. In such
instances, the student may be disciplined in the same manner as a nondisabled student would be disciplined for the use of illegal drugs or alcohol.
THE FOLLOWING HAVE BEEN CONSIDERED:
In relationship to the behavior subject to disciplinary action, was the conduct in question, caused by, or did it have a direct
Consensus of the Section 504 Team Yes
No
and substantial relationship to, the student’s disability?
Was the conduct in question the direct result of the school district’s failure to implement the Section 504 Accommodation
Consensus of the Section 504 Team Yes
No
Plan?
If the answer to both 1 and 2 is “No,” then the behavior is NOT considered a manifestation of the disability and further
disciplinary sanctions/consequences are appropriate.
If the answer to either 1 or 2 is “Yes,” then the behavior IS considered a manifestation of the student’s disability and
further disciplinary sanctions are not appropriate.
NOTE: IF the accommodation plan is NOT being implemented, further suspension is not appropriate and the 504
Committee MUST develop a plan to implement. Stop manifestation meeting, sign form, and develop plan to ensure
implementation of the accommodation plan.
FOLLOW UP ACTIVITIES RECOMMENDED BY THE TEAM:
O Readdress the Section 504 Accommodation Plan
O Obtain consent and complete an FBA
O Refer to the PST
O Other
MANIFESTATION DETERMINATION TEAM MEMBERS
LEA/Designee:
Guidance Counselor:
Principal/Designee:
Gen. Ed Teacher:
Parent/Guardian:
Dean:
Student:
Other:
Other:
Other:
I have received a copy and explanation of the Parent/Student Rights in identification, evaluation, and placement under
Section 504 of the Rehabilitation Act of 1973.
Parent/Guardian Initials ___________ Date _____/_____/_____
Place Original in Cumulative folder
Copy to Parent
Copy to Student Services
STS 0091 Rev. 3/29/10
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