321 East Ohio Street, Marquette MI 49855

PH: 906.226.5165 FAX: 906.226.5168

www.maresa.org

SCHOOL DISTRICT/LOCAL CONTACT NUMBER:

Worksheet for Determining A Pattern of Behavior

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:

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 -

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

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abrouill

2011-02-04

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