Fillable BIE Section 504 Manifestation Determination Form (Bureau of Indian Affairs)

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BIE Section 504 Manifestation Determination Form (Bureau of Indian Affairs)

On average this form takes 16 minutes to complete

The BIE Section 504 Manifestation Determination Form (Bureau of Indian Affairs) form is 2 pages long and contains:

  • 2 signatures
  • 6 check-boxes
  • 54 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Bureau of Indian Affairs

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Section 504 Manifestation Determination
Student’s name:
School:
Grade:
Parent’s Name:
Address:
Home Phone:
Work Phone:
Behavior:
Date of Behavior:
Date of Meeting:
Consideration of all relevant student information, including: Check all relevant boxes:
Evaluation and diagnostic results
Relevant information provided by the parent
Observation of the student
Current 504 Plan and placement
All relevant information in the
students file
School Health Information
Other:
Other:
Other:
Other:
Date of:
--/--/----
Manifestation Review:
Behavior:
1. Behavior subject to disciplinary action:
504
Accommodation
Plan or referral
2. Student’s disability (504):
MANIFESTATION DETERMINATION:
For each statement answer either “YES” or “NO” and provide an explanation.
___ YES
___ NO
1. The conduct in question was the direct result of the district’s failure to implement
the student’s 504 plan.
Explain:
___ YES
___ NO
2. The conduct in question was caused by or had a direct and substantial
relationship to the student’s disability(ies).
Explain:
FINAL DETERMINATION:
___ YES
The conduct/behavior is a manifestation of the student’s disability.
Check “YES” if at least one answer to the above questions is Yes.
Signature/Title ______________________ __________________________
Date: __________ Email/Phone/Contact: ________________________________
___NO
The conduct/behavior is NOT a manifestation of the student’s disability.
Check “NO” if both answers to the above questions are No
Signature/Title ______________________ __________________________
Date: __________ Email/Phone/Contact: ______________________________
__
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Signatures and Printed Names
Position
Date
Parent
504 Coordinator
Teacher
School Administrator or
Designee
Person Knowledgeable About
Evaluation Data
Other:
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BIE Section 504 Manifestation Determination Form (Bureau of Indian Affairs)

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Completed 26 January 2021

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