2014 – 2015
MISSISSIPPI DEPARTMENT OF EDUCATION – OFFICE OF SPECIAL EDUCATION
ACCOUNTABILITY STANDARD 17.4
ON-SITE MONITORING RECORD REVIEW FORM
DISCIPLINE
*For students who have been suspended 10 days plus or expelled
District:
Student’s Name:
Date of Review:
School:
Age:
Grade:
Eligibility:
Monitor’s Name:
Eligibility Date:
NOTES:
Revised August 2014
Record Review Form
Page 1 of 5
2014 – 2015
MISSISSIPPI DEPARTMENT OF EDUCATION – OFFICE OF SPECIAL EDUCATION
ACCOUNTABILITY STANDARD 17.4
ON-SITE MONITORING RECORD REVIEW FORM
DISCIPLINE
*For students who have been suspended 10 days plus or expelled
Record
Review
Item
DIS-1
DISCIPLINE
DIS-2
Regulation
34 CFR or
SBP 7219
300.530(e)(1)
300.536
300.530(e)(1)
300.530(g)
300.536
Record Review
Question
Compliant
If necessary, did the
district conduct a
manifestation
determination to
determine the
relationship of the child’s
behavior of concern to
the child’s disability?
Was the manifestation
determination conducted
within 10 school days of
the district’s decision to
change the placement of
a child with a disability?
(Change of placement is
disciplinary removal of a
child for violation of
student code of conduct
and removal if for more
than ten consecutive
school days or series of
removals constitute a
pattern).
YES
A Manifestation Determination
Review Form was completed by the
team.
NO
A Manifestation Determination
Review Form was not completed by
the team.
Yes
No
NA
Revised August 2014
Evidence
Potential Source(s)
of Documentation
* Manifestation
Determination
Review Form
The date of the manifestation
* Student discipline
determination review is not more than
record
10 school days from the date of the
documenting
decision to change the placement of a
cumulative days of
child with a disability through a school
out-of-school
suspension or expulsion.
suspension or
expulsion, from
The date of the manifestation
which the
determination review is more than 10
manifestation
school days from the date of the
determination
decision to change the placement of
review timeline
the child with a disability through a
can be calculated.
suspension or expulsion.
Special Circumstances: School
personnel may remove a student to
an interim alternative educational
setting for not more than forty-five
(45) school days without regard to
whether the behavior is determined to
be a manifestation of the child’s
disability for possession of a weapon,
possesses or uses illegal drugs, or
inflicts serious bodily injury.
Record Review Form
Page 2 of 5
2014 – 2015
MISSISSIPPI DEPARTMENT OF EDUCATION – OFFICE OF SPECIAL EDUCATION
ACCOUNTABILITY STANDARD 17.4
ON-SITE MONITORING RECORD REVIEW FORM
DISCIPLINE
*For students who have been suspended 10 days plus or expelled
Regulation
34 CFR or
SBP 7219
DIS-3
300.530(b)(2)
DISCIPLINE
Record
Review
Item
Record Review
Question
Compliant
If required, did the
district continue to
provide services to a
student after he or she
has been removed from
his or her current
placement for 10 school
days in the same school
year, during any
subsequent days of
removal?
Evidence
There is evidence regarding the
provision of educational services
following the tenth day of removals.
YES
NO
There is evidence regarding the offer
to provide educational services
following the tenth day of removal, but
the child did not participate in the
services.
There is no evidence documenting
the provision of educational services
following the tenth day of removals.
The child did not receive educational
services.
Revised August 2014
Record Review Form
Potential Source(s)
of Documentation
* Attendance
Records
* Service Provider
Logs
* Revisions to IEP to
discuss change in
placement
Student discipline
records documenting
cumulative days of
out-of-school
suspension or
expulsion from which
the manifestation
determination review
timeline can be
calculated.
Page 3 of 5
2014 – 2015
MISSISSIPPI DEPARTMENT OF EDUCATION – OFFICE OF SPECIAL EDUCATION
ACCOUNTABILITY STANDARD 17.4
ON-SITE MONITORING RECORD REVIEW FORM
DISCIPLINE
*For students who have been suspended 10 days plus or expelled
Regulation
34 CFR or
SBP 7219
DIS-4
300.530(c)
300.530(d)
300.530(f)(1)
(i)(ii)
300.530(g)
DISCIPLINE
Record
Review
Item
Record Review
Question
Did the district conduct a
functional behavioral
assessment (FBA) after
the manifestation
determination? (Unless
the district conducted the
FBA before the behavior
that resulted in the
change in placement.)
Compliant
Evidence
An FBA is included in the student’s file.
YES
Potential Source(s)
of Documentation
*Functional Behavior
Assessment
The FBA meets the requirements of SBP
300.530(d).
Disciplinary change of placement that
would exceed ten school days is
determined not to be a manifestation of
the child’s disability.
NO
Disciplinary change of placement for a
violation of a code of conduct to an
interim alternative educational setting for
not more than forty-five school days for
weapons, drugs or serious bodily injury.
The FBA was conducted, but it does not
meet the requirements of SBP
300.530(d).
NA
Revised August 2014
The team determined that the conduct
was not a manifestation of the student’s
disability.
Record Review Form
Page 4 of 5
2014 – 2015
MISSISSIPPI DEPARTMENT OF EDUCATION – OFFICE OF SPECIAL EDUCATION
ACCOUNTABILITY STANDARD 17.4
ON-SITE MONITORING RECORD REVIEW FORM
DISCIPLINE
*For students who have been suspended 10 days plus or expelled
DIS-5
300.530(d)
300.530(f)(1)
(i)(ii)
Revised August 2014
Did the district develop a
behavioral intervention
plan (BIP) for the child as
a result of the FBA?
OR
If the BIP had already
been developed, did the
district review the BIP
after the manifestation
determination and modify
it as necessary to
address the child’s
behavior?
A BIP is included in the student’s file.
YES
NO
NA
* Behavioral
Intervention Plan
The BIP meets the requirements of SBP
300.530(d).
A BIP is not included in the student’s file.
The BIP is included, but it does not meet
the requirements of SBP 300.530(d).
The team determined that the conduct
was not a manifestation of the student’s
disability.
Record Review Form
Page 5 of 5