GREENWICH PUBLIC SCHOOLS
GREENWICH, CONNECTICUT
SECTION 504 MANIFESTATION DETERMINATION WORKSHEET
Student’s Name Date of Birth
School
Date of Meeting
Grade
Meeting Facilitator
Mental or Physical Impairment
A.
Sources of Information:
Teacher Counselor
Title
School records review (dated)
Grades & report card review (dated)
Observations of student (dated)
Teacher reports (dated)
Parent and/or student report (dated)
Medical information (dated)
Standardized testing (dated)
Informal assessments (dated)
Nursing assessment (dated)
Parent/Student interviews
(dated)
Disciplinary Report (dated) Checklists, behavior ratings (dated)
Developmental/Social History (dated)
B.
Review student’s history of disciplinary action:
C. Describe student’s history of behavioral interventions:
D. Describe the violation of the school code of conduct:

E. Does the proposed suspension constitute a change in placement, i.e. more than 10 days or a series of short-term suspensions that constitute a change in placement?
No: Proceed with the suspension.
Yes: Answer the following:
Describe the characteristics and the severity of the student’s disability:
To what degree does the student’s disability prevent an understanding of the impact and consequences of the code of conduct violation?
To what extent does the disability restrict the student’s ability to control the behavior at issue?
Has the behavior or similar behaviors associated with the disability been exhibited in the past?
Explain:
Is the misconduct directly caused by the student’s physical or mental impairment?
Is the student’s 504 Accommodation Plan appropriate?
Were the consequences of violations of the school code of conduct explained to the student?

Any other relevant information discussed at the meeting? (Optional section)
Based on the information noted above, is the violation of the school code of conduct a manifestation of the student’s disability?
No – The student may be disciplined using procedures applicable to non-disabled students.
Yes – Reevaluate the student’s 504 Plan for appropriateness. A new functional behavioral assessment should be completed or existing one revised. The student may not be suspended.
A.
504 Team Members Present and Roles
________________________________________________ ___________________________________
Section 504 Multidisciplinary Team Leader Date of Meeting