IEP/IFSP Facilitation/Mediation Request Form - Office for Dispute Resolution

Date

Requested By:

Parent/Guardian
LEA (school district; charter; or IU)
Infant/Toddler / Early Intervention
Parent Attorney
LEA Attorney

Name of Person Completing this Form:

First Last

Email of Person Completing this Form:

Relationship to Student:

Mother
Father
Guardian
N/A

Phone:

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

Please check the type of service requested:*

IEP Facilitation
Mediation
GIEP Facilitation
IFSP Facilitation (Early Intervention)

Student Information

Student Name:

First Last

Date of Birth:

Date format: MM/DD/YYYY

Exceptionality(ies):

Name of School/Program:

Parent/Guardian Information

Parent/Guardian Name(s):

First Last

Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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:

Name:

First Last

Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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:

For Parent/Guardian Requests

Will the parent be represented by an attorney at mediation? If yes, please provide the information below.

Yes
No

Attorney Name:

Attorney Email:

Attorney Phone:

Attorney Address:

Local Education Agency (LEA) Information

School District / Charter School / Agency Name:

Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Contact Name:

First Last

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?

Yes
No

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

CAPTCHA

Mediation Request Form (IEP/IFSP) (English) - Accessible

Student Information

Parent/Guardian Information

Second Parent or Parent not residing with the Student:

For Parent/Guardian Requests

Local Education Agency (LEA) Information

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