DISCIPLINARY ACTION DOCUMENTATION FORM
DEPARTMENT OF CHILDREN AND FAMILIES
OFFICE OF EDUCATION
DISCIPLINARY ACTION DOCUMENTATION FORM
Education program:_________________________________ Date:____________________________
Student’s name: ___________________________________ D.O.B.: __________________________
Eligibility category:__________________________________
Disciplinary action: _________________________________
Student behavior resulting in suspension: ___________________________________________________
_____________________________________________________________________________________
Setting of suspension: ( home ( other: ___________________________________________________
Date(s) of suspension:__________________________ Number of school days (this incident):__________
Total number of school days suspended this school year:______________
Does this suspension constitute a “Change of Placement”? Why or why not?
Is the provision of services required? Why or why not?
If educational services are required, extent and description of services:
As needed, IEP Team meeting date (no later than 10 business days after taking disciplinary action):________________
Purpose of meeting:
___ Conduct a Manifestation Determination ___ Develop a Functional Behavioral Assessment
___ Develop a Behavioral Intervention Plan ___ Review/modify an existing Behavioral Intervention Plan
___ To address deficiencies in the IEP, placement or implementation
Outcomes of the above referenced meeting(s): (attach additional documentation as needed)
Participants involved in making decisions regarding this Disciplinary Action:
__________________________________________________________ _____________
Printed Name and Signature of person completing this form Date
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