STUDENT HEARING AND PLACEMENT DEPARTMENT

(SHPD-F003)

5735 47TH Avenue, Box 760

Sacramento, CA 95824

Public Line (916) 643-9425	Fax Number (916) 643-2125

*All Requested Information (blanks) must be completed

CENTRAL BEHAVIOR REVIEW REQUEST	VIOLATION OF CONTRACT

(attach copy of District Behavior Contract)

School:	EPAL Score:	DOB:

Student Number:	Ethnic Code:	Grade:	Gender:

Student Name:	Parent/Legal Guardian Name:

Address:	City:	State:	Zip Code:

Home Telephone:	Cellular Telephone:	Work Telephone:

Date of SST:
Special Education Program:	None	DIS	ED	LD	RSP	SDC	SH	504 Plan: Yes No	If yes, date of initial plan: (attach copy)
Date of IEP: (attach copy)	If an alternative placement is going to be considered, does the IEP support it? Y N
Manifestation Determination Date: Required for students who receive Special Education services (attach copy)	Positive Behavior Plan or Functional Analysis: Date Plan was recommended: (attach copy)	Yes No
“Any Student receiving Special Education services and who is being considered for a Central Behavior Review at the SHPD must have a Positive Behavior Support Plan. The plan must have been in place prior to the referral to SHPD, with sufficient time to demonstrate its effectiveness through documentation, i.e. 4-6 weeks.”

Accumulative Days Suspended this School Year: (drop down field)	Number of times Suspended this School Year: (drop down field)

Education Code Violation(s) 48900: (as indicated on latest suspension form)	(), (), ()

Behavior Review	Violation of Contract
Brief description of incident:

Principal or Designee (Title)	Signature	Date