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

*Date of written request from parent(s):
(MM/DD/YYYY)

*Name of Child:

*Date of Birth:
(MM/DD/YYYY)

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)

County MH/ID Office Information

*County MH/ID Office:

Name of County MH/ID Contact Person:

Title:

Address:

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

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

Email:

Fax:
ex: 000-000-0000

County Legal Representative (if applicable)

Name:

Address:

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

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

Email:

Fax:
ex: 000-000-0000

Schedule hearing with:County MH/ID Contact PersonLegal Representative

Parent(s) Information

*Name(s):

*Address:

*Home Phone:
ex: 000-000-0000

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

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

Email:

Parent Representative Information

Parent representative:
Insert the name or “None”

Title:

Address:

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

Email:

Fax:
ex: 000-000-0000

Schedule hearing with:Parent(s)Representative

*Reason for hearing:

Time of Hearing Preferred:9:00 am - 12:00 pm1:00 pm - 4:00 pm5:00 pm - 7:00 pm

Type of hearing: Open to the PublicClosed (participants only)

Language preferred by the parents:

Alternative mode of communication:

County MH/ID office has provided a site for the hearing accessible for individuals with disabilities at the following address:

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

*Name:

*Email:

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