Sample Due Process Complaint Notice Form To Request An Impartial Hearing
Sample Due Process Complaint Notice Form
English - Word (58 KB) or PDF (110 KB)
Spanish - Word (63 KB) or PDF (44 KB)
Russian - Word (71 KB) or PDF (115 KB)
Korean - Word (61 KB) or PDF (101 KB)
Chinese (Simplified) - Word (61 KB) or PDF (121 KB)
Haitian-Creole - Word (60 KB) or PDF (44 KB)
This sample form may be used to submit a complaint (also known as a request for an impartial hearing) to resolve a disagreement about the identification, evaluation or placement of a student with a disability or a student suspected of having a disability or regarding the provision of a free appropriate public education for such student under the Individuals with Disabilities Education Act (IDEA).
Party Submitting the Complaint Notice
- Requests for a due process hearing must be made in writing.
- All asterisked (*) information on this form is required under section 300.508(b) of the Code of Federal Regulations and section 200.5(i)(1) of the Regulations of the Commissioner of Education and must be included when you submit a Due Process Complaint Notice to request an impartial hearing.
- If you, or your attorney, do not include the asterisked (*) items on this form, it may result in the denial or delay of a resolution session and/or a due process hearing and the reduction of any attorney’s fees awarded by a court.
- You may request mediation, at any time, including prior to filing a due process complaint notice.
- When a due process hearing is requested by the parent, the parent must agree to meet with the school district to try to resolve the problem before the hearing begins. This meeting, called a Resolution Session, must occur within 15 days after the school district receives the parent’s due process complaint notice. However, the parent and the school district may agree to pursue mediation to resolve the problem or may agree to proceed with the impartial hearing, rather than have a Resolution Session.
Party Receiving This Notice
- If you believe the notice is not sufficient (does not fully provide the required asterisked information), you may notify the appointed impartial hearing officer and the other party in writing within 15 days of receipt of this notice. The impartial hearing officer must decide if the notice is sufficient within five days of the sufficiency request and notify both parties in writing.
- Within 10 days of receiving a due process complaint notice, you must send to the other party a response that specifically addresses the issues raised in the request.
- If the school has not sent prior written notice to the parent regarding the subject matter contained in the parents’ due process complaint notice, the school district must send a response to the parent within 10 days of receiving the due process complaint notice in accordance with section 1415(c)(2)(B)(i)(I) of IDEA.
For Additional Information
For additional information on special education and the Procedural Safeguards Notice, refer to http://www.p12.nysed.gov/specialed/publications/home.html.
Instructions: Complete, sign and make two copies of the original form.
- Send the original form to the:
- parent if the school is requesting the hearing.
- Board of Education if the parent is requesting the hearing.
- Send one copy to the New York State Education Department, P-12: Office of Special Education, 89 Washington Avenue, Room 309 EB, Albany, New York, 12234. Attention: Impartial Hearing Reporting System.
- Retain a copy for your records.
Due Process Complaint Notice
I, the undersigned, do hereby file this Due Process Complaint Notice against ___________________________ (school or parent).
Submitted by: _____________________________________________
Submitted to: _____________________________________________
* Child's Name: _________________________
Date of Birth:______________________
*Address of the Residence of the Child (if any):_____________________
*Name of the School the Child is Attending: _________________________
Address of the School the Child is Attending: _____________________
Name of the School District or State Agency Responsible of the Provision of Services: _____________
*Additional Contact Information for the Homeless Child or Youth (if available): _____________
Name of Parent or Person in Parental Relation; or Surrogate Parent (if applicable): ____________
Mailing Address of Parent, Guardian or Surrogate Parent (if applicable): _________________
Name of School Representative or Contact (if known):___________________
Mailing Address of School or Agency Central Office: ____________________
Subject of the Complaint
*Describe the nature of the problem (the concerns that led you to request this hearing), including all specific facts relating to the problem, Attach additional pages or documents as necessary.
*State your proposed resolution of the problem to the extent known and available at this time. Attach additional pages or documents as necessary.
|Name of Person Completing This Form:||Signature:|
__ Parent or Person in Parental Relationship
__ Surrogate Parent
__ Parents’ Attorney
__ School District/State Agency Representative
__ School District/State Agency Attorney
Is there another due process complaint (impartial hearing) in process for this same student?
Yes ____ No _____
If yes, who is the appointed impartial hearing officer? __________________
Did you, or another representative of the parent, submit a due process complaint notice for this same student within the last 12 months that was later withdrawn?
Yes _____ No _____
If yes, who was the appointed impartial hearing officer? ______________________