IEP/IFSP Facilitation/Mediation Request Form

En EspañolEn Español

Download a printable version of this form

Request Form for IEP/IFSP Facilitation & Mediation.

Fill out the following form online.
The form must be completed in its entirety with a value for all required fields. Partial forms cannot be saved and accessed at a later date.

Requested By:Parent/GuardianLEA (school district; charter; or IU)Infant/Toddler / Early Intervention

Name of Person Completing this Form:

Email of Person Completing this Form:

Relationship to Student:MotherFatherGuardianN/A

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

Please check the type of service requested:IEP FacilitationMediationGIEP FacilitationIFSP Facilitation (Early Intervention)

Student Information

Last Name:

First Name:

Date of Birth:
MM/DD/YYYY

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)

Name of School/Program:

Parent/Guardian Information

Parent/Guardian Name(s):

Last Name:

First Name:

Address
Street, Apt. No., PO Box, etc. and City / State / ZIP:

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

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

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

Email:

Second Parent or Parent not residing with the Student:

Last Name:

First Name:

Address
Street, Apt. No., PO Box, etc. and City / State / ZIP:

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

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

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

Email:

Local Education Agency (LEA) Information

School District / Charter School / Agency Name:

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

Contact Name:

Position Title:

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

Fax:
ex: 000-000-0000

Email:

Please provide a brief description of the issue(s) in dispute, and any proposed solutions to the problem*:

Please complete this section if you are requesting any type of facilitation service.

An IEP/IFSP/GIEP meeting is currently scheduled for:
date, time and location

Location of IEP meeting:

An IEP/IFSP/GIEP meeting has not yet been scheduled. Not scheduled

Has a due process hearing already been requested? YesNo

For all requests, if there is additional information you would like to provide, please enter it here:

  • Parents with questions about these services or other dispute resolution options may contact the Special Education ConsultLine at 800-879-2301 or 717-901-2146” .
  • Any birth-3 questions should be referred to OCDEL at 717-346-9320.
  • On occasion, an ODR staff person may ask to attend any of these meetings for purposes of evaluating the service. Parties will be notified ahead of time, and any questions will be addressed at that time.