Prior Written Notice Of District'S Proposal/refusal Form

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PRIOR WRITTEN NOTICE OF DISTRICT’S PROPOSAL/REFUSAL

Hancock County Schools

Student’s Full Name: ____________________________________________________

Date: ________________________

School: _______________________________________________________________

DOB: _________________________

Parent(s)/Guardian(s): __________________________________________________

Grade: _______________________

Address: _____________________________________________________________

WVEIS #: ____________________

City/State: ___________________________________________________________

Telephone: __________________

Dear ______________________________________,

As a result of:

___ a Student Assistance Team (SAT) meeting conducted on ____________________,

___ an Eligibility Committee (EC) meeting conducted on ________________________,

___ an Individualized Education Program (IEP) Team meeting conducted on ______________________,

___ a disciplinary action occurring on _____________________________,

___ other _________________________________________________________.

the district is providing you with written notice of the district’s ___proposal / ___ refusal of the following action(s) with regard to:

___ the educational evaluation or reevaluation of the student.

___ the identification of the student as having a disability.

___ the educational services and/or placement of the student.

___ the provision of a free appropriate public education (FAPE) to the student.

___ other______________________________________________________.

Specifically, the district is proposing _________________________________________________

The district is proposing or refusing this action because: ______________________________________________________.

The evaluation procedure(s), assessment(s), record(s) or report(s) the district used as a basis for the ___ proposed/ ___ refused

action are:. _____________________________________________________________________________________.

Other options considered include: _____________________________.

The reasons the above options were rejected are: _______________________________________________..

Other factors relevant to the district’s ___ proposal / ___ refusal are: ______________________________________.

Exceptional students and their parents have protections under the procedural safeguards. A copy of the Procedural Safeguards Brochure and assistance in

understanding the provisions of the procedural safeguards may be obtained by contacting the Director of Special Education at 304-564-3411, as appropriate, the local

Parent Educator Resource Center at __________________ and/or the West Virginia Department of Education, Office of Special Programs at 304-558-2696 or 1-800-

642-8541.

Sincerely,

__________________________________________

Signature/Position

Date

West Virginia Department of Education

July 2013