Florida Department of Education



District School Board of Pasco County

Dispute Resolution Request Form

District Complaint Form – This form is to be used for filing a discrimination complaint with the District School Board of Pasco County, when alleging that a school has violated the educational rights of a student: (check one)

with disabilities, under the Individuals with Disabilities Education Act (IDEA 2004) and corresponding state requirements, or

with disabilities under Section 504 of the Rehabilitation Act of 1973, or

who qualifies for gifted services according to state requirements.

* Required Fields Please print or type

*Date:     

*Name of individual or organization filing the complaint:      

*Address:     

*City:       *State:       *Zip Code:     

*Home Telephone #      *Cell #:      *Work #:      

Email Address:      

Best time to reach you:      

*Student’s Name:      

Student’s Age:       Student’s Grade:       * Student’s Exceptionality:      

*Your relationship to the student:      

*School Name:      

* District Complaint:

• I am alleging that            (school name), has violated state and/or federal requirements regarding the identification, evaluation or provision of appropriate educational services for the student named above.

• I understand I must include the facts that support my allegation(s).

• I also understand this complaint must allege a violation that occurred not more than one year prior to the date that the complaint is received by the district.

* These are the facts that lead me to believe that there has been a violation of federal and/or state education laws.

     

This is the remedy or suggested solution I think would resolve this problem.

     

I understand I will be contacted by district staff assigned to my case to:

• clarify and review my complaint facts

• submit additional information or documentation to support my statement (if needed)

• advise me of my rights to alternative resolution activities

___________________________________________                

* Signature of Complainant * Date

Check here if you have attached additional sheets.

Check here if you have included documents as evidence that support your facts.

Please return this complaint by US mail, email or fax to:

Melissa Musselwhite, Director,

Office for Student Support Programs and Services:

District School Board of Pasco County

7227 Land O’Lakes Blvd.

Land O’ Lakes, FL 34638

mmusselw@pasco.k12.fl.us

Fax: (813) 794-2117

Please call (813) 794-2600 if you have any questions.

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download