Complaint Investigation Request Form - California Department Of Education printable pdf download

California Department of Education

Special Education Division

Procedural Safeguards Referral Service

Revised 11/2006

REQUEST FOR COMPLAINT INVESTIGATION

PLEASE NOTE: A complaint may be filed through the use of this form or by a written letter sent by fax or postal mail. E-

mails cannot be accepted as formal complaints because they do not meet signature requirements under 34 C.F.R.

300.153(b)(3). If upon analysis of a request, a complaint is opened, a complaint investigation will be completed within 60

days of receipt in the California Department of Education (CDE) Special Education Division Procedural Safeguards

Referral Service (PSRS) of all required information.

The written complaint must specify at least one alleged violation of state and/or federal special education laws

that occurred not more than one year prior to the date the complaint is received by the CDE. The party filing a

complaint must forward a copy of the complaint to the LEA or public agency serving the child at the same time

the party files a compliance complaint with the CDE. [34 Code of Federal Regulations (CFR) 300.153(d)]

Please return the completed form to: California Department of Education; Special Education Division; Procedural

Safeguards Referral Service; 1430 N Street; Suite 2401; Sacramento, CA 95814; Phone: 800-926-0648;

FAX: 916-327-3704

Name of School District or other Public Educational Agency that allegedly violated state and/or federal special

education laws:

_________________________________________________________________________________________________

Complainant Contact Information:

Name____________________________________________________________________________________________

Address__________________________________________________________________________________________

City________________________________________________, CA Zip Code__________________________________

Phone Numbers (Please note the best time to call):

(day)_________________________________________(evening)____________________________________________

(work)______________________ext._______________(fax)________________________________________________

Parent/Guardian Information (if different from above):

Name(s)_________________________________________________________________________________________

Address_________________________________________________________________________________________

City______________________________________________________, CA Zip Code____________________________

Parent/Guardian Phone Numbers (if phone contact is permitted, please indicate the best time to call):

(day)______________________________________________(evening)_______________________________________

(work)______________________ext.____________________(fax)___________________________________________

Student Information (If alleging violations with respect to a specific child):

Name____________________________________________________________________________________________

Date of Birth _____________________________Current Grade Level_________________________________________

Address Where Student Resides (If different from Parent/Guardian information):

Address__________________________________________________________________________________________

City________________________________________________, CA Zip Code__________________________________

School of Attendance (required) _______________________________________________________________________

Complaint Investigation Request Form - California Department Of Education