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PROCEDURAL SAFEGUARDS NOTICE

Parent Attorney:

Attorney Phone:

Attorney Email:

Address:

Attorney Fax:

Local Education Agency (LEA) Information

I.   LEA Contact

Last Name:

First Name:

Position Title:

Cell Phone:

Work Phone:

Fax:

Email:

Address:

II.  Superintendent/CEO

Last Name:

First Name:

Position Title:

Address:

Phone:

III. LEA Attorney

Last Name:

First Name:

Attorney Phone:

Attorney Email:

Address:

Attorney Fax:

IV. The Due Process Hearing will be held at the following address:

    (Building Name, Address and Room Number/Name – to be completed by the LEA)

Information About the Due Process Complaint Notice

A.  Does your issue pertain to a Hearing Officer Decision which has not been implemented?

Yes

No

(If yes, the Bureau of Special Education will be notified, and will investigate the matter. Due Process is not available when the issue pertains to non-implementation of a Hearing Officer Decision.)

B.  Is this request for an expedited hearing?

Yes

No

If yes, please check one of the reasons below:

Disciplinary (drugs/weapons)

ESY (Extended School Year)

Check here if Student is in the ESY Target Group

C.  The law states that a party may not have a due process hearing until a Due Process Complaint Notice is filed, which meets all of the legal requirements. An opposing party may challenge the sufficiency of the Due Process Complaint Notice if it is lacking sufficient information. You must describe the nature of the problem giving rise to this request for due process, including as many facts to support your position as possible. You must also provide a proposed resolution of the problem to the extent known and available to you. You may attach a separate sheet of paper if you need more space:

Nature of the problem:

30July 2008 Revisions

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