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Administrative Complaint
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Request for Due Process
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Request for Mediation
Administrative
Complaint
To: ATTN: Legal Services
Tennessee Department of Education
Division of Special Education
5 th Floor,
Andrew Johnson Tower
710 James Robertson Parkway
Nashville, Tennessee 37243-0380
FAX: 615.253.5567
From: __________________________________________________________
Name
__________________________________________________________
Address
__________________________________________________________
City
State
Zip Code
__________________________________________________________
Telephone
(Home)
Telephone (Work)
_________________________________________________
Child’s
Name
_______________________
_____________________
Child’s
Date of
Birth
Child’s Disability
I wish to file an administrative complaint on behalf of
____________________,
a student at __________________________ School, in
the_____________________ School System.
The specific grounds/reasons for this complaint are as
follows:_______________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Please investigate this complaint and notify me of the
results. I understand that it may be necessary
to release a copy of any correspondence submitted by me in relation to
this complaint, my name,
the name of the child, and the nature of my complaint to local school
system officials in order to
resolve these issues.
___________________________________ _____________ |
Signature
Date
ACFORM 01/02/01
Request for Due Process Hearing
PARENT INFORMATION (To
be completed by parents and returned to the School System for processing)
Name of Child ________________________ Name of
Parent/Guardian __________________
Child/Parent/Guardian Address
__________________________________________________
City _________________________________ Zip _______ Telephone
Number_____________
Attorney for Child/Parent/Guardian
________________________________________________
Attorney's Address
____________________________________________________________
City _________________________________ Zip _______ Telephone
Number_____________
Complete description of the nature of the problem of the
child relating to identification, evaluation, educational placement
(initial or proposed change) or the provision of a free appropriate public
education (FAPE).
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
A proposed resolution of the problem to the extent known
and available to the parents.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
NOTE: Failure on the part of the parents and/or attorney
representing the child to comply with this section
could cause a reduction in the amount of attorney’s fees if the child is
the prevailing party.
SYSTEM INFORMATION
(LEA must complete information and establish two agreed upon hearing
dates)
School System
________________________ System Administrator ____________________
School System Address
______________________________________________________
City _________________________________ Zip _______ Telephone
Number____________
School Attended _______________________ Disability
______________________________
Attorney for School System
_____________________________________________________
Attorney's Address
___________________________________________________________
City _________________________________ Zip _______ Telephone
Number____________
Date Request Received by School System ____________ Place
Hearing to be Held _______
Two (2) Agreed upon Dates for Hearing to be Held
_______________Open ____Closed ____
Mail and/or fax this request along with a copy of the
letter from the parent/guardian and/or attorney to:
ATTN: Legal Services
Tennessee Department of Education
Division of Special Education
5th Floor,
Andrew Johnson Tower
710 James Robertson Parkway
Nashville, TN 37243-0380
FAX: 615-253-5567
Special Education Mediation Request
ATTN: Legal Services
Tennessee Department of Education
Division of Special Education
5th Floor, Andrew Johnson Tower
710 James Robertson Pkwy.
Nashville, TN 37243-0380
FAX: 615-253-5567
We would like to request special education mediation on
behalf of _______________________
a student in ____________________________ Schools.
Disability _____________________________________
_____ We understand this request is for mediation
only. A due process hearing
has not been requested.
_____ We understand this request is for mediation
concurrent with a request for a due
process hearing. A written request for a hearing has been forwarded to the
Superintendent of Schools.
Summary of issues to be mediated:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Preferred date(s), time(s), and place for Mediation
Conference:
___________________________________________________________________________
Sincerely, __________________________ _______________________________
*Parent
Signature
*School System Signature
Parent/Guardian
School System Administrator
Name __________________________ Name
________________________
Address ________________________ Address
______________________
City ___________________________ City
__________________________
Zip Code Phone _________________ Zip Code
Phone ________________
*Not Valid Unless Both Parties Have Signed
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