Infant-Toddler Early Intervention Due Process Request Form

* indicates a required field

A due process hearing request form is submitted to the ODR within three (3) calendar days from the date of written request. Documentation such as a copy of the IFSP (draft accepted) or evaluation, etc. shall be submitted by mail, fax, or email to the ODR. The email address is ODR@odr-pa.org. Additional contact information may be found on the ODR website or the printable version of this form. Submit copies of request to parent(s) and regional office. Maintain a file copy in MH/ID office.

Student Information


(MM/DD/YYYY)


(MM/DD/YYYY)

County MH/ID Office Information






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

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

County Legal Representative (if applicable)




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

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

Parent(s) Information





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

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

Parent Representative Information


Insert the name or “None”



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


ex: 000-000-0000







Please include a Google Maps link to the site of the hearing:
> Click here for a simple tutorial about creating a map link

Person completing this form




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