Prior Written Notice Ohio Form – Fill Out and Use This PDF

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Dear John & Josephine Parent:

This is to notify you of the district’s action: regarding Sally Student’s educational program.

1. Type of action taken:

Proposes to initiate an initial evaluation Refusal to initiate an evaluation Expedited evaluation

Change of placement

Change of placement for disciplinary reasons

Proposes to change the identification, evaluation or educational placement of the child or provision of FAPE

Refusal to change the identification, evaluation or educational placement of the child or provision of FAPE

Reevaluation

IEP issues/meetings where the parent(s) disagree with the district Revocation of Consent

Due process hearing, or an expedited due process hearing, initiated by the district Graduation from high school

Exiting high school due to exceeding the age eligibility for FAPE Other

Type of action other text box data entry.

2. A description of the action proposed or refused by the school district:

RICH TEXT BOX

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3. An explanation of why the school district proposes or refuses to take the action:

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4.A description of other options that the IEP team considered and the reasons why those options were rejected:

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5.A description of each evaluation procedure, assessment, record or report the school district used as a basis for the proposed or refused action:

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6. A description of other factors that are relevant to the school district's proposal or refusal:

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PROVISION OF PROCEDURAL SAFEGUARDS

As a parent of a child with a suspected or identified disability, you have procedural safeguard protection under the Individuals with Disabilities Education Improvement Act (IDEIA) of 2004. Upon initial referral for an evaluation or parent request for an evaluation, You will be given a copy of your procedural safeguards once per year. In addition, you will also be given a copy of the procedural safeguards upon when you request a copy, when your child is referred for their first evaluation, when you request an evaluation for your child, when you file a formal written complaint or request a upon receipt of the first state complaint under 34 C.F.R. S300.151-300.153 and upon receipt of the first due process hearing and under 34 C.F.R. S300.507 in a school year and in accordance with the discipline procedures in 34 C.F.R. S300.530 (h).

If you have any questions about the action(s) described in this form, your rights as described in the Procedural Safeguards Notice, other related concerns, or you wish to obtain a copy of the Procedural Safeguards notice, please contact the following:

Please contact Name and Title: ___________11 ______________________________

at Phone #:_____11a__________ if you have any questions about the action(s) described above,

your rights, as described in the Procedural Safeguards Notice, or other related concerns. You may also obtain a copy of the procedural safeguards notice from the following:

Name:

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Title: _____________________________

Address:_____________________________________________________________

City, State, Zip Code: ___________________________________________________

Telephone: __________________ E-mail: _________________________________

School District: ________________________________________________________

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Enclosure: Procedural Safeguards Notice