To: Due Process Coordinator, Special Services Team, Maine Department of Education, Station #23, Augusta, ME 04333-0023 Date of Receipt by DoE:
Type of due process requested (select one):
___ Mediation ___ Complaint ___ Hearing ___Expedited Hearing
If requesting a complaint or a hearing are you willing to participate in mediation? __ Yes __ No
(A mediation will not interfere with the timelines for a complaint or a hearing.)
Parent's name:
Address:
Telephone: Home:_____ - ______ Work:_____ - ______ Fax:_____ - ______
Student's name:
Date of Birth: ____/____/____ Disability:
If the complainant is any person other than the student's parent or legal guardian, OR if the student is 18 years of age or older, and not subject to legal guardianship, the signature of the parent or legal guardian/adult student is required in order to release personally identifiable information as part of the dispute resolution process.
____________________________ Signature of parent/legal guardian/adult student.
Student's Residence (if different from parent):
School district the student attends:
School: Grade:
Is the student tuitioned to the school listed above? ____ Yes ____ No
If Yes, from which town or district?
Attorney / advocate:
Address:
Telephone: (_____)_____ - _______ Fax: (_____)_____ - _______
Describe the nature of the problem and any facts relating to the problem. (Attach additional pages if necessary.):
How could this problem be resolved? (Attach additional pages if necessary.):
What actions has the school taken to address the problem?:
FOR PARENT, ADULT STUDENT OR INTERESTED PARTY:
Did you notify the school of this problem? ____ Yes ____No
Person notified: _________________________ Date notified: ___/___/___
How you notified the school:
(MSER §13.2B)
FOR SCHOOL ADMINISTRATIVE UNIT:
Did you notify the parent or adult student of the initiation of this request for due process? ____ Yes ____No
Person notified: _________________________
Date notified: ___/___/___
* Attach copy of letter from Superintendent to parents or adult student (MSER § 13.2C)
Signature of individual submitting request:
___________________________________________ Date: ____/____/___
For additional information or assistance you may wish to contact:
- The superintendent or special education director of the school district
- The Maine Department of Education, Due Process Office - 624-6644 fax: 624-6641, email: patricia.neumeyer@state.me.us
- The Special Needs Parent Information Network (SPIN) - 1-800-870-7746
Note to parents requesting a due process hearing: Recent amendments to state and federal laws concerning special education services for students with disabilities requires parents or their attorneys to provide the information contained within this form to the State Department of Education and the local school district. Failure to provide this information may result in a reduction in the award of any attorney fees. (20 U.S.C. §1415 (b)(7), (i)(3)(F)) and Title 20-A MRSA § 7207-B, §§3-A.
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