321 East Ohio Street, Marquette MI 49855

PH: 906.226.5165 FAX: 906.226.5168

www.maresa.org

SCHOOL DISTRICT/LOCAL CONTACT NUMBER:

DIRECTIONS FOR COMPLETING

Worksheet for Determining A Pattern of Behavior

GUIDANCE: This form should be used to determine if a series of removals constitutes a pattern of removals. The form can serve as a running record of the incidents subject to removes for a student. Only one form needs to be completed for each student for each school year. Each incident and decision by the team is recorded on the same form.

The use of this form is not required. However it does provide documentation of the district’s process for determining a pattern of behavior if the district is monitored and involved in a hearing or state complaint.

Student:
Date of Birth:
Grade:
School:

PARTICIPANTS

The following individuals participated in this Manifestation Determination Review Meeting. Additional participants should be noted and attached to this form [34 CFR §300.344].

Name/Role:
Name/Role:

Name/Role:
Name/Role:

GUIDANCE: IDEA does not specify who should be part of the school team to determine if a pattern of removals has occurred. The MDE recommends that staff familiar with the student, including the student’s special education teacher, be involved in the determination of a pattern of behaviors. If the team members change for subsequent determinations, note the dates next to each member in attendance.

Description of Behavior/Incident Subject to Discipline

List all incidents subject to disciplinary action for current school year	Date of Suspension	Number of days of suspension	Cumulative days of suspension	Proximity of removals
Incident #1 -
Incident #2 -
Incident #3 -
Incident #4 -
Incident #5 -
Incident #6 -
Incident #7 -

GUIDANCE: Use this chart to keep a running record of the student’s suspensions. By completing the chart for each incident, the team will be able to see all of the behaviors subject to suspension as well as the number of days of removal, the proximity of removals, and cumulative days of removal.

The first column requires a description of the behavior and incident subject to discipline. The incident should be described in detail so that the team can use it to look at the connection between the behavior of the student in the current incident and previous incidents. Statements should include, when available: activities that went on before the incident; other people involved; statements made by the student and others before, during and after the incident.

The second column is the date of the current suspension.

The third column is the number of days in the current suspension.

The fourth column is the cumulative number of days of suspension, including the current number of days of removal.

The fifth column would specify the proximity of removals, detailing the number of days, weeks or months since the last incident.

Determination of Pattern of Removals	Rationale for Determination
Incident #1 Yes

No
Incident #2 Yes

No
Incident #3 Yes

No
Incident #4 Yes

No
Incident #5 Yes

No
Incident #6 Yes

No
Incident #7 Yes

No

GUIDANCE: Use this chart to record the decision of the team regarding whether there is a pattern of removals. Each cell in the first column references an incident in the first chart (Description of Behavior). The conclusion of the team in incident #1 would be recorded on the first column of the second chart (Determination of Pattern) in the cell labeled Incident #1, and so forth for each incident.

The second column would document the rationale for the team’s decision regarding the pattern of removals. The cell next to Incident # is shaded since a pattern would only be observed after the second incident.

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2011-02-04

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