OFFICE OF ADMINISTRATIVE HEARINGS STATE OF CALIFORNIA

SPECIAL EDUCATION DIVISION

REQUEST FOR DUE PROCESS HEARING AND MEDIATION REQUESTED ON BEHALF OF STUDENT

Student’s Information:

Student’s first and last name:

Student’s birthdate:

Student’s main language:

Student’s address, including the street address, city and zip code:

Student’s grade level. For example, if student is in second grade, then write “second grade.”

Name of the school student goes to:

Student’s school district of residence:

Parent Information:

All of the information requested below is required if student is under 18 years of age.

For each parent to be included in this Request for Due Process Hearing and Mediation, please write the information in the space below. If the student has a legal guardian or an educational rights holder then please put their name and information under the Parent Number 1 section, and add either “legal guardian” or “educational rights holder” after their name.

FIRST PARENT INFORMATION:

First and last name for Parent Number 1:

Phone numbers for Parent Number 1: Cell Phone:

Work Phone:

Home Phone:

Home address for Parent Number 1, including the street address, city and zip code:

If an interpreter is needed for Parent Number 1, please state the language in the space below. For example, if Parent Number 1 needs a Spanish interpreter, please write “Spanish” in the space below.

SECOND PARENT INFORMATION, TO BE COMPLETED ONLY IF THERE IS A SECOND PARENT:

First and last name for Parent Number 2:

Phone numbers for Parent Number 2: Cell Phone:

Work Phone:

Home Phone:

Home address for Parent Number 2, including the street address, city and zip code:

If an interpreter is needed for Parent Number 2, please state the language in the space below. For example, if Parent Number 2 needs a Spanish interpreter, please write “Spanish” in the space below.

Parties to be Named by Parents or Student Filing this Request

Only public agencies, such as those listed below, may be named. Do not list individual people who may work for a public agency. The parties to be named for this case must include at least one of the following:

• School district student currently attends, will attend, or did attend;
• Charter school student currently attends, will attend, or did attend;
• County office of education, or
• Other public agencies involved in any decision regarding the student.

Please provide the name and address of the public agency or agencies with whom you wish to schedule a due process hearing and mediation.

Identify the Specific Problems or Complaints:

Federal and state law require you to describe in detail the nature of the problem or problems you want included in this complaint. Simply describing a problem in general terms, such as “Student was denied FAPE for school year 2005-2006,” is not enough. You must include facts, dates, references to specific individual education program provisions – also known as “IEP” provisions -, etc. Failure to specifically describe the problem or problems to be included in this complaint may result in this case being closed. Closing a case is called a dismissal.

Describe the nature of the problem including all important facts. Provide details. You may add more if needed.

PROBLEM OR COMPLAINT NUMBER 1:

PROBLEM OR COMPLAINT NUMBER 2:

PROBLEM OR COMPLAINT NUMBER 3:

Proposed Resolution of Problems Stated Above

“Proposed Resolution of Problems” means how you want each of the problems described above to be solved. Federal law requires that you provide a solution to each of the problems described in this complaint to the extent you know the solution. You must describe the solution with as much detail as you can.

Describe the solution for each of the problems outlined above.

SOLUTION TO PROBLEM OR COMPLAINT NUMBER 1:

SOLUTION TO PROBLEM OR COMPLAINT NUMBER 2:

SOLUTION TO PROBLEM OR COMPLAINT NUMBER 3:

Signature of Party Requesting Due Process Hearing and Mediation

Print the name of the party requesting a due process hearing and mediation in the space below.

Print the email address for the party requesting a due process hearing and mediation in the space below.

The party requesting the due process hearing and mediation, or their representative, must sign and date in the space below.

STATEMENT OF SERVICE

Federal and state laws require you to send or deliver a copy of this Request to each of the named parties.  Additionally, you must send or deliver a copy to the Office of Administrative Hearings. Retain a copy for yourself.  Please indicate that you have sent copies of this Request by checking the appropriate box below.

I have provided a copy of this Request for Due Process Hearing and Mediation to all the named parties and to the Office of Administrative Hearings by:

First Class Mail to the person or agency named below at the address listed below. Please include the date the document was mailed to that person or agency.

Facsimile transmission, also referred to as fax, or email to the person or agency named below at the fax number or email listed below. Please include the date the document was faxed or emailed to that person or agency.

Messenger or overnight delivery such as UPS, FedEx, or other courier service to the person or agency named below using the service identified below. I have also attached a copy of the receipt.

Personal delivery to the person or agency listed below at the address shown below. I have included the name of the person who made the delivery and the date and time of the delivery.

Signature of person completing this statement

Print the name of the person completing this Statement of Service in the space below.

The person completing this Statement of Service must sign in the space below and write the date of the signature next to the signature.

By typing your name in the space below you are consenting to electronically signing this document.