Chapter 7: When Things Aren't Going Well

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Dispute Resolution Request Form

To:	Due Process Coordinator Special Services Team, Maine Department of Education, Station #23, Augusta, ME 04333-0023 Date of Receipt by DOE:

Type of dispute resolution requested (select one):

___Mediation ___ Complaint ___ Hearing ___Expedited Hearing

If requesting a complaint or 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 #1's Name: ____________________

Address: ____________________

Telephone: Home:____-____Work:____-____Fax:_____-_____

Parent #2's Name____________________

Address:____________________

Telephone: Home:_____ - ______ Work:_____ - ______ Fax:_____ - ______

If the complaintant 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 informtion as part of the dispute resolution process. ________________________________ Signature of parent/legal guardian/adult student.

Student’s name: ____________________

Date of Birth: ____/____/____

Disability: ____________________

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.):

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How could this problem be resolved? (Attach additional pages if necessary.):

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What actions has the school taken to address the problem?:

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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: ____/____/___

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For additional information or assistance you may wish to contact:

• The superintendent or special education director of the school district
• The Maine Dept of Education, Due Process Office - Tel: 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 require 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)