1. Name, birthdate, & grade of the child.

2. Disability category: Provide a list of all disabilities that currently apply to the child. If the child has not been identified as a child with a disability, state "Child has not been identified" in the space provided.

3. Address of the residence of the child; or in the case of a homeless child or youth, available contact information.

4. Name & address of the school the child is attending.

5. Parent Name & address, if address is different from child's; or in the case of a homeless child or youth, available contact information for the child: "Homeless" means homeless within the meaning of section 725(2) of the McKinney-Vento Homeless Assistance Act, 42 U.S.C. 11434a(2); & phone numbers.

6. Mediation: Mediation is a free service provided by the State to resolve disputes. Participation in mediation is completely voluntary and must be agreed to by both parties. A mediator will arrange dates for the parties to discuss remedies to resolve the dispute. Mediation is concurrent with due process, but the mediation meeting will usually be scheduled before the due process hearing takes place. If you are interested in mediation, please check the applicable line.

7. Description of the Problem & Facts Relating to the Problem: Provide a description of the nature of the problem which is the basis of your request for a due process hearing, & provide facts relating to the problem. Example of Problem: The problem is the school district's failure to implement my child's IEP. Example of Facts Relating to the Problem: My child has not received the speech & language services specified in her IEP.

8. Description of the Proposed Resolution: State the resolution you are proposing to the extent known & available to you at the time. Example of Proposed Resolution: I am proposing that my child receive the speech & language services specified in her IEP.

9. Attorney or Representative: If you have an attorney or representative in this case, please provide the name & address of the attorney or representative. If this section is completed by the parent or LEA, all due process correspondence & information will be sent to the attorney or representative & not to the parent or LEA.

10. Signature: Party requesting the hearing is required to print, sign, & date the complaint notice/due process hearing request.

11. Expedited Hearing, if Applicable: A parent may request an expedited hearing only if the parent disagrees with the decision regarding placement for disciplinary removals or with the manifestation determination. A local educational agency (LEA) may request and expedited hearing only if the LEA believes that maintaining the current placement of the child is substantially likely to result in injury to the child or to others. An expedited hearing may not be requested for any other reason.

12. Submission of Request: Send the original completed request to the other party, and send a copy to the Ohio Department of Education, Office for Exceptional Children, Procedural Safeguards, 25 South Front Street, Columbus, Ohio 43215-4183 or fax a copy to (614) 728-1097.

DUE PROCESS COMPLAINT AND REQUEST FOR A DUE PROCESS HEARING

CHILD'S NAME ON WHOSE BEHALF THE HEARING IS REQUESTED

CHILD'S BIRTHDATE (mm/dd/yyy) 

GRADE

DISABILITY CATEGORY

ADDRESS OF THE CHILD'S RESIDENCE; OR IN THE CASE OF A HOMELESS CHILD OR YOUTH, AVAILABLE CONTACT INFORMATION

NAME & ADDRESS OF THE SCHOOL THE CHILD ATTENDS

PARENT NAME & ADDRESS, IF ADDRESS IS DIFFERENT FROM CHILD'S. IN THE CASE OF A HOMELESS CHILD OR YOUTH, AVAILABLE CONTACT INFORMATION FOR THE CHILD

HOME PHONE ____________________

CELL PHONE ____________________

WORK PHONE ____________________

DAYTIME PHONE ____________________

A BILINGUAL OR SIGN LANGUAGE INTERPRETER IS REQUESTED

q YES  q NO   IF YES, specify language/mode of communication

NAME OF SUPERINTENDENT & SCHOOL DISTRICT OF RESIDENCE

A DESCRIPTION OF THE PROBLEM (Describe the nature of the problem of the child relating to a proposed initiation or change of placement or provision of a FAPE) (Attach additional pages if necessary).

FACTS (Provide facts relating to the problem described above) (Attach additional pages if necessary).

A DESCRIPTION OF THE PROPOSED RESOLUTION YOU ARE SEEKING (Provide the proposed resolution of the problem to the extent known & available to the party at the time) (Attach additional pages if necessary).

NAME & ADDRESS OF THE ATTORNEY OR REPRESENTATIVE FOR THE PARENT/GUARDIAN OR LEA. If this section is completed, all information & correspondence regarding the due process hearing request will be sent to the attorney or representative & not to the parent or LEA.

PHONE NUMBER

FAX NUMBER

THE PARTY REQUESTING THE HEARING IS (Check one):

q Parent/Guardian of the child on whose behalf the hearing is being brought

___________________________________

Name (printed) of Party Requesting Hearing

q School District of Residence (Superintendent)

___________________________________

Signature of Party Requesting Hearing

q Other Educational Agency (Name):

______________________________

___________________________________

Date of Signature (mm/dd/yyyy)

q Student with a Disability Who Is At Least 18 years Of Age But Not More Than 21 years of Age.

REQUEST FOR EXPEDITED HEARING (COMPLETE THIS SECTION ONLY IF YOU ARE REQUESTING AN EXPEDITED HEARING)