Manifestation Determination Review Summary

Student: [Full legal name], [DOB], [Student ID per local policy]

School/District: [School name], [District/LEA], [Grade/Program]

Meeting Date: [MM/DD/YYYY], Time: [Start–End], Location: [Location], Modality: [in-person / virtual / hybrid]

Author: [Name], [Credentials], [Role]

Documentation Date: [MM/DD/YYYY] (Only include if different from meeting date)

Record Type: Education record (FERPA)

Trigger for MDR & Procedural Context

[Disciplinary action being considered and basis for potential change of placement] (If a voluntary/preventive MDR not tied to a change of placement, explicitly state this and explain why the review was convened.)

• Date of incident: [MM/DD/YYYY]
• Date decision made to pursue removal: [MM/DD/YYYY]
• Date MDR occurred: [MM/DD/YYYY]
• Total removal days this school year: [Number]
• Special circumstances: [weapons / drugs / serious bodily injury / none] (Only include if applicable)
• Interim Alternative Educational Setting (IAES): [involved / not involved] (If involved, specify: [IAES type], [Start–End dates])

(If any key date or detail is missing, insert a placeholder such as [MISSING: date of incident] and add a follow-up task.)

Participants

• Parent/Guardian(s): [Name(s)] — Participation: [in-person / phone / video / written input / absent] (If absent, document contact attempts: [Dates/methods])
• LEA Representative(s): [Name(s), Role(s)]
• IEP Team Members: [Name(s), Role(s)] (Note how relevant members were selected)
• Teachers: [General education teacher name(s)], [Special education teacher name(s)]
• Related Service Providers: [Name(s), Discipline(s)]
• Interpreter: [Language provided] (Only include if used)
• Student: [attended / did not attend]
• Absent required attendee(s): [Name(s)] — [How input was obtained] (If attendance unknown, note this and add follow-up task)

Incident Summary

(Provide a concise, factual, chronological description. Avoid subjective labels; do not infer intent unless clearly documented. Reference attached incident report(s) rather than duplicating verbatim. Include direct quotes only if materially relevant to MDR analysis. Use "peer" rather than student names.)

• Date/Time: [MM/DD/YYYY HH:MM]
• Location: [Setting]
• Involved parties: [Staff], [Peer(s)], [Other]
• Observable behaviors: [Factual chronological sequence]
• Immediate consequences: [Removal / De-escalation / Restraint or seclusion / Injuries / Law enforcement] (Include only what occurred)
• Referenced reports: [Incident report date(s) and record location]

Student Disability & Educational Profile

(Include only information relevant to the MDR questions. Do not add new diagnoses. Include medical/mental health details only if provided to the team and directly relevant.)

• Eligibility category: [Category] — Primary behavioral impacts: [Brief description]
• Current placement/services: [Setting, hours, key services]
• Behavioral accommodations/modifications in IEP: [Key items]
• Behavior Intervention Plan (BIP): [present / not present], [Date last reviewed]
• Functional Behavioral Assessment (FBA): [completed / not completed], [Date]
• Behavioral patterns (data-supported): [Brief summary across settings/time]
• Relevant medical/mental health information: [Summary] (Only if directly relevant and provided to team)

Information Reviewed

(List all information reviewed per IDEA requirements. If a relevant document exists but was not reviewed, state why.)

• [IEP(s) with date(s)]
• [Evaluations/assessments with date(s)]
• [Teacher observations and behavior logs]
• [Parent-provided information]
• [Discipline history and cumulative removal days]
• [Implementation fidelity data: service logs, accommodation checklists]
• [BIP progress monitoring data]
• [Other relevant records]
• [Document not reviewed: title] — [Reason not reviewed] (Only include if applicable)

MDR Analysis

Question 1: Was the conduct caused by, or did it have a direct and substantial relationship to, the student's disability?

Determination: [Yes / No]

Evidence and reasoning: [Explanation of how specific disability-related impairments do or do not relate to the conduct, referencing data across time/settings when available, contextual factors documented, competing explanations considered, and if uncertainty exists, what is unknown and why the team reached this conclusion] (Label professional opinions explicitly and base on reviewed information)

Question 2: Was the conduct the direct result of the LEA's failure to implement the IEP?

Determination: [Yes / No / N/A if no IEP]

Evidence and reasoning: [IEP components relevant to incident, evidence of implementation or non-implementation reviewed, and if non-implementation occurred, what was missed and how it plausibly contributed to the conduct]

Team Determination

Final outcome: [Manifestation / Not a Manifestation]

• Basis: [Question 1 positive / Question 2 positive / Both]
• Decision process: [Consensus / Not consensus]
• Parent/guardian position: [Agreement / Disagreement / Unable to attend] — [Written input summary if provided]
• (If manifestation due to failure to implement IEP, state that LEA will remedy deficiencies)

Placement & Services

• Placement decision: [Return to prior placement / IAES / Removal continues]
• IAES details: [Type], [Start–End dates], [Service plan] (Only include if applicable)
• Educational services during removal: [Plan to enable participation in general curriculum and IEP goal progress] (Only include if not a manifestation or during IAES)

Required Follow-Up Actions

(List each required task with owner and deadline. Include tasks to obtain any missing information documented elsewhere in this note. If no additional actions are required, state "No additional follow-up actions required.")

• [Conduct FBA / Review FBA currency] — Owner: [Name/Role] — Due: [Date]
• [Develop/implement or review/modify BIP] — Owner: [Name/Role] — Due: [Date]
• [Remedy IEP implementation deficiencies] — Owner: [Name/Role] — Due: [Date] (Only if applicable)
• [Plan re-entry supports] — Owner: [Name/Role] — Due: [Date]
• [Educational service plan during removal/IAES confirmed] — Owner: [Name/Role] — Due: [Date]
• Procedural Safeguards Notice provided: [MM/DD/YYYY] — By: [Name/Role]
• [Schedule follow-up IEP meeting] — Owner: [Name/Role] — Due: [Date] (Only if needed)
• [Distribute meeting summary per local procedure] — Owner: [Name/Role] — Due: [Date]

Attachments

• [Incident report(s): date(s), storage location]
• [Discipline log/removal summary: date range, storage location]
• [Relevant IEP pages: date(s), section(s)]
• [BIP: date, storage location]
• [FBA summary: date, storage location]
• [Implementation logs/accommodation checklists: date range, storage location]
• [Written parent input: date, storage location]
• [Other documents: description, storage location]

(Document the team's determination as a team decision, not a unilateral conclusion. Clearly separate facts, reported information, and professional opinion throughout.)