Mississippi Department of Education
Mississippi Department of Education
Office of Special Education
REQUEST FOR DUE PROCESS HEARING UNDER PART B
OF THE INDIVIDUALS WITH DISABILITIES EDUCATION ACT 2004 AMENDMENTS
I, _______________________________________ am requesting a hearing before a State Level Hearing Officer.
Your name
_________________________________________ ____________________________________________
Child’s name Parent’s name
_________________________________________ ____________________________________________
Address of the residence of the child Parent’s address
_________________________________________ ____________________________________________
Child’s resident district and school Parent’s phone number_________________________
Email Address _____________________________
This problem(s) results from: Proposal to initiate or change: Refusal to initiate or change:
____ The child’s identification ____ The child’s identification
____ The child’s evaluation ____ The child’s evaluation
____ The child’s educational placement ____ The child’s educational placement
____ Provision of a free appropriate ____ Provision of a free appropriate
public education to the child public education to the child
Describe the following (use additional sheets of paper if more space is needed).
The nature of the problem(s) relating to the proposal or refusal indicated above:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
The facts of this case relating to the above problem(s):
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Your proposed resolution of the problem(s):
___________________________________________________________________________________________
___________________________________________________________________________________________
I/we agree to participate in a mediation process.
(This will not delay the opportunity for a hearing.) □YES □ NO
___________________________________________________________________________________________
____________________________________________ ____________________________________________
Parent Signature Date Form Completed ____________________________________________
____________________________________________ ___________________________________________
*Address and phone number of person filing request, *Position/role of person filing request, if not parent
if not parent (example: superintendent or attorney or parent representative)
This is a model form. The above information is required, however, you may use another form of documentation in conveying your request to the Office of Special Education.
*If an attorney or other individual representing the parent completes this form on behalf of the parent, an authorization for representation signed by the parent must accompany this form.
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8-31-11
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