Due Process Complaint Notice

* indicates a required field

Please Choose:IDEAIDEA & Gifted EducationGifted EducationSection 504

*Requested By:ParentLEA

*Name of Person Completing this Request:

*Email of Person Completing this Request:

*Relationship to Student:

*Phone:
ex: 000-000-0000 or 000-000-0000x000

After completing this online form, you will receive a copy of the submitted information via email. The information contained in this email should be sent to the opposing party.

If you require special accommodations to participate in the due process hearing, you must notify the LEA.

Student Information

*Last Name:

*First Name:

DOB:

Gender:MaleFemale

Exceptionality(ies):AutismDeaf-BlindnessDevelopmental DelayEmotional DisturbanceGiftedHearing Impairment (including Deafness)Intellectual DisabilityMultiple DisabilitiesNot eligibleOrthopedic ImpairmentOther Health ImpairmentProtected HandicappedSpecific Learning DisabilitySpeech or Language ImpairmentThought to have disabilitiesThought to be giftedTraumatic Brain InjuryVisual Impairment (including Blindness)

*LEA (Local Education Agency):
Eg: School District

*School Building Student Attends:
Eg: ABC Elementary School

Parent(s) Residing with Student

*Last Name:

*First Name:

*Relationship:MotherFatherGuardian

*Home Phone:
ex: 000-000-0000 or 000-000-0000x000

Cell Phone:
ex: 000-000-0000 or 000-000-0000x000

Work Phone:
ex: 000-000-0000 or 000-000-0000x000

Email:

Preferred method of written correspondence:U.S. MailEmail

Second Parent at Same Address

Last Name:

First Name:

Relationship:MotherFatherGuardian

Home Phone:
ex: 000-000-0000 or 000-000-0000x000

Cell Phone:
ex: 000-000-0000 or 000-000-0000x000

Work Phone:
ex: 000-000-0000 or 000-000-0000x000

Email:

Preferred method of written correspondence:U.S. MailEmail

Parent(s)/Student Address:

Parent(s)/Student Address:

Parent(s)/Student City:

Parent(s)/Student Zip:

Parent Attorney (if represented):
Full Name of Attorney

Attorney Address:
Street, PO Box, Floor, Rm Number, etc. and City / State / ZIP

Attorney Phone:
ex: 000-000-0000 or 000-000-0000x000

Attorney Email:

Parent(s) Not Residing with Student

Last Name:

First Name:

Relationship:MotherFather

Home Phone:
ex: 000-000-0000 or 000-000-0000x000

Cell Phone:
ex: 000-000-0000 or 000-000-0000x000

Work Phone:
ex: 000-000-0000 or 000-000-0000x000

Email:

Preferred method of written correspondence:U.S. MailEmail

Parent(s) Address:

Parent(s) Address:

Parent(s) City:

Parent(s) Zip:

Parent Attorney (if represented):
Full Name of Attorney

Attorney Address:
Street, PO Box, Floor, Rm Number, etc. and City / State / ZIP

Attorney Phone:
ex: 000-000-0000 or 000-000-0000x000

Attorney Email:

Local Education Agency (LEA) Information

I. LEA Contact Person Information

Last Name:

First Name:

Position Title:
Principal/Superintendent, etc.

Cell Phone:
ex: 000-000-0000 or 000-000-0000x000

Work Phone:
ex: 000-000-0000 or 000-000-0000x000

Email:

Address:
Street, PO Box, Floor, Room, etc. and City / State / ZIP

II. Superintendent/CEO

Last Name:

First Name:

Position Title:
Superintendent, CEO, Administrator, etc.

Address:
Street, PO Box, Building, Room, etc. and City / State / ZIP

Phone:
ex: 000-000-0000 or 000-000-0000x000

III. LEA Attorney

Full Name of Attorney:

Attorney Address:
Street, PO Box, Floor, Rm Number, etc. and City / State / ZIP

Attorney Phone:
ex: 000-000-0000 or 000-000-0000x000

Attorney Email:

IV. The due process hearing will be held at the following address:

(to be completed by the LEA)

Building Name, Street Address, Room, etc.

Note: The hearing will be held at a time and place reasonably convenient to parents and child involved. For gifted education cases, the hearing will be held in the school district at a place reasonably convenient to the parents, and, at the request of parents, may be held in the evening.

Information About the Due Process Complaint
(IDEA Cases Only)

A. Does your issue pertain to a hearing officer decision which has not been implemented?YesNo

If yes, the Bureau of Special Education will be notified, and will investigate the matter. Due process is not available when the issue pertains to non-implementation of a hearing officer decision.

B. Is this a request for a hearing based on a disagreement about:DisciplineESY (Extended School Year)

Check if student is in the ESY target group

Information About the Due Process Complaint (All Cases)

You may use the following fields to explain the nature of your dispute.

*What is this dispute about? Please include facts in your description.

*How would you like to see this resolved? What are you seeking?

If you know the other side's position about this problem, please describe it here.

Resolution Meeting (IDEA Cases Only)
Prior to a due process hearing taking place, if the parent filed the due process complaint, the law requires the parties to participate in a resolution meeting, unless both sides agree in writing to waive this requirement. Please complete the following information:

1. A resolution meeting to discuss these issues is scheduled for:
(MM/DD/YYYY)

2. A resolution meeting was held on:
(MM/DD/YYYY)

3. Participation in the resolution meeting was waived by both parents and the LEA in writing on:
(MM/DD/YYYY)

4. In lieu of a resolution meeting, I am requesting mediation.

If #4 is checked, an ODR mediation case manager will be in contact with the partner.

If you are requesting mediation in lieu of a resolution meeting you must submit a mediation request form.

Please save a copy of the email you receive. An ODR staff member will confirm receipt of complaint and provide case manager and hearing officer information.

Additional information about due process is available on this website; or by calling the Special ConsultLine, 800-879-2301.