Providing Resources For Parents and Educators
* indicates a required field
Please Choose:IDEAIDEA & Gifted EducationGifted EducationSection 504
*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.
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
*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
Preferred method of written correspondence:U.S. MailEmail
Second Parent at Same Address
Home Phone:ex: 000-000-0000 or 000-000-0000x000
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
Parent(s) Not Residing with Student
Local Education Agency (LEA) Information
I. LEA Contact Person Information
Position Title: Principal/Superintendent, etc.
Address: Street, PO Box, Floor, Room, etc. and City / State / ZIP
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:
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.
©2012 Office for Dispute Resolution • 6340 Flank Drive Harrisburg, PA 17112 • 800-222-3353