New York State Education Department
Sample Due Process Complaint Notice Form
To Request An Impartial Hearing

PDF PDF document (53 KB) or Word word document (50 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 referral, evaluation or placement of a student or regarding the provision of a free appropriate public education for a student under the Individuals with Disabilities Education Act.

Party Submitting the Complaint Notice

Party Receiving This Notice

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.
·      
the 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: _____________________________________________

 

Date:               _______________________

 

 Student Information

*Child’s Name:
 

  Date of Birth:
 

*Address of the Residence of the Child (if any):   

*Name /Address of the School the Child is Attending: 

  Name of School District or State Agency Responsible for the Provision of Services: 

* Additional Contact Information for Homeless Child or Youth: 

 

Parent Information

Name of Parent or Person in Parental Relation; or Surrogate Parent (if applicable):  

Mailing Address of Parent, Guardian or Surrogate Parent (if applicable): 

Telephone:

 

 

School Information

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 disagreement.  Attach additional pages or documents as necessary.

 

 

 

 

 

 

 

 

 

 

 

Proposed Solution:

*State your proposed solution to 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:

Check one:

____ Parent or Person in Parental Relationship

____ Surrogate Parent

____ Parents’ Attorney 

 ____ School District/State Agency Representative

 ____ School District/State Agency Attorney

Date: