Title
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Date Sent (mm/dd/yyyy) *
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Student's Full Name *
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Date of Birth (mm/dd/yyyy) *
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This is to notify you of the district's action regarding the student's educational program.
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1. Type of Action Taken (choose all that apply) *
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2. Describe the action proposed or refused by the school district *
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3. Explain why the school district proposes or refuses to act *
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4. Describe other options considered by the IEP team and the reasons for rejection *
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5. Describe each evaluation procedure, assessment, record or report the district used for the proposed or refused action *
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6. Describe other factors relevant to the district's proposal or refusal *
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7. Provide for Procedural Safeguards: As a parent of a child with a suspected/identified disability, you have procedural safeguards under IDEA. Upon initial parent request or referral for an evaluation, you have access to your procedural safeguards.
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7. You will be given a Proced Sfgds copy upon request, upon receipt of 1st state complaint (34 CFR 300.151-300.153) & upon receipt of 1st due process request (34 CFR 300.507) in a school year & in accordance w/ the discipline procedures 34 CFR 300.530 (h)
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7. Please contact Name, Title, & Phone (if you have any questions about the action(s) decribed above, your rights, as described in Procedural Safeguards Notice, or other related concerns. *
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7. You may also obatin a copy of the procedural safeguards notice from the following:
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Name of District Person *
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Address *
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Title of District Person *
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Phone (xxx-xxx-xxxx) *
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Email *
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School District *
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Link to Procedural Safeguards Notice *
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Effective date: 2/1/07
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