120 / 190
1342.12 Companion
July 12, 2017
Page 120
Discipline Summary Checklist for Removals less than 10 Consecutive Days but Total
Removals in the School Year Exceed 10 Cumulative Days
Student:
Date of Discipline Referral:
Date of Pattern Meeting:
If determined “NO” Pattern:
_________________ Date student removed for ______days
_________________ Date services provided for removed days
Identify services:
_________________ Date parent notified of above
If determined “YES” Pattern this is a Change of Placement:
________________ Date parent notified of change of placement
_________________ Date parent provided Procedural Safeguards Notice
_________________ Date parent notified of Manifestation Determination Review (MDR) Meeting
_________________ Date of MDR Meeting (must be held within 10 days of removal)
Parent WAS
☐
WAS NOT
☐
in attendance at the MDR meeting.
If "YES" Manifestation:
_________________ Date student returned to school (must be returned within 10 days of removal
decision)
_________________ Date FBA addressed
_________________ Date BIP addressed (if appropriate)
If "NO" Manifestation:
_________________ Date CSC convened to determine services provided
_________________ Date student removed for ______days
_________________ Date services provided for removed days
Identify services:
_________________ Date FBA addressed
_________________ Date BIP addressed (if appropriate)