Model Due Process Complaint/Request for Hearing Form



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ichigan Department of Education

Office of Special Education

608 West Allegan Street

Lansing, Michigan 48909

Telephone: (517) 373-2979

Toll Free: (888) 320-8384

Fax: (517) 373-8414
Model Due Process Complaint/Request for Hearing Form
PURPOSE: This model form may be used to submit a request for a due process hearing to resolve a disagreement about the identification, evaluation, eligibility, educational placement, or manifestation determination of a student, or regarding the provision of a free appropriate public education for a student under the Individuals with Disabilities Education Act (IDEA).
INSTRUCTIONS: Complete this form and mail, fax, or hand-deliver it to the Michigan Department of Education (MDE), Office of Special Education (OSE) at the address above. You must also provide a copy to the school district(s) that the due process complaint is against. The complaint will not be filed until the MDE and the district(s) have received a copy of the complaint. The use of this form is not required; it is provided to assist in filing a state complaint.
Note: The * indicates required information. This information must be provided whether you use this form or any other format. Complaints that do not have all required information will NOT be filed and will be returned to the complainant.



COMPLAINANT CONTACT INFORMATION

*Name:      

*Address:

     


Telephone Number(s):      


Email address:      




STUDENT INFORMATION

*Name of Student:      

Age:

     


Date of Birth:      

Grade:      

*Address of Student (or contact information if student is homeless):

     



Name of Parent or Guardian (if other than the person filing the complaint):      


Resident District:      




SCHOOL INFORMATION

*Name of the School the Student Attends:      

Name of the District(s) the Complaint is Filed Against:      



*PROBLEM AND FACTS

What is the nature of the problem that relates to the student’s special education program and what are the facts that relate to the problem? Include dates, if known. (Attach additional pages if necessary.)

     




*PROPOSED RESOLUTION

Briefly explain how you think the issue should be resolved. (Attach additional pages if necessary.)

     




*STATEMENT OF DELIVERY

Check one of the boxes below and fill in the information below the selected box.

 A copy of this due process complaint was sent to the district(s) by mail:

Addressed to:

     

Date mailed:

     






(Name of Person)










 A copy of this due process complaint was sent to the district(s) by fax:

Addressed to:

     

Date mailed:

     

Time Sent:

     






(Name of Person)
















 A copy of this due process complaint was delivered to the district(s) in person:

Addressed to:

     

At:

     

Date:

     






(Name of Person)




(Place it was Delivered)










_________________________ _______________________________ ________________

Printed Name *Signature Date

MEDIATION
The Michigan Department of Education (MDE) encourages parents and districts to resolve disputes through informal dispute resolution processes, including mediation.
Mediation is a voluntary process. A trained, impartial mediator assists the parties in reaching a mutually acceptable resolution of the dispute between the parties. Mediators are not affiliated with any local school district nor do they represent any of the parties in a complaint. Discussions during mediation are confidential.
The MDE provides mediation services at no cost to the complainant or the district if they use the Michigan Special Education Mediation Program (MSEMP). The MSEMP is funded by an MDE grant.
If you are interested in resolving a complaint through mediation or informal resolution, the MDE will, with your consent, forward your name and telephone number to the MSEMP. The MSEMP will contact you to tell you more about mediation and other alternative dispute resolution options. If you choose to participate in mediation, the MSEMP will contact the district to determine if the district agrees to participate in mediation. If so, the MSEMP will make the arrangements and schedule the mediation meeting(s).
If you and the district agree to participate in mediation after a due process complaint has been filed, the hearing timeline may be extended until the mediation process is completed. If the issue is resolved through mediation, the complaint will be withdrawn or dismissed. If the issue is not resolved, the MDE will proceed with the due process hearing.
For more information about mediation and informal dispute resolution, see the MDE Special Education Due Process Complaint Procedures or contact the Michigan Special Education Mediation Program (MSEMP) at (800) 8RESOLVE or http://msemp.cenmi.org.

Please provide the information below and sign your name if you want the MSEMP to contact you to tell you more about mediation and other informal dispute resolution options.
I am interested in resolving the complaint against the __________________________ school district/public school academy through mediation or informal resolution.
I give the MDE permission to forward my name and telephone number to the MSEMP.
Name: ___________________________ Telephone number: _________________________
______________________________________________ _________________________

Signature Date ……………………………………………………………………………………………………………………………………………………………


FOR MDE USE ONLY: Case # _____________ Date Filed _______ Administrative Law Judge ________________



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