Idr Form A - Request For Informal Dispute Resolution (Idr) Regarding Individualized Education Program (Iep) Issues
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2REF-1410.3
LOS ANGELES UNIFIED SCHOOL DISTRICT
Attachment B-1
Division of Special Education
October 23, 2006
Request for Informal Dispute Resolution (IDR)
Regarding Individualized Education Program (IEP) Issues
IDR Form A
Student: __________________________________________________________ DOB ________________ Gender: ___________
School of Attendance ________________________ School of Residence ___________________________ Local Dist. ________
Eligibility: _________________________ Location of IEP Meeting: __________________________ IEP Date: ______________
Date IEP Signed: _________________ Placement: _________________________ Language of Student: ___________________
Parent(s)/Guardian Name: _____________________________________________________ Language of Parent: _____________
Home Address: _________________________________________________________________________
(Street)
(City)
(Zip)
Phone: Home: ( ) ________________ Work: ( ) ________________ Fax: ( ) _________________ Cell: ( ) _______________
List the issues that are in dispute from the IEP. These issues should be jointly developed by the IEP Chairperson and the parent. Attach a
copy of the IEP in which the dispute arises and pertinent assessment reports.
1. _______________________________________________________________________________________________________
_______________________________________________________________________________________________________
2. _______________________________________________________________________________________________________
_______________________________________________________________________________________________________
3. _______________________________________________________________________________________________________
_______________________________________________________________________________________________________
4. _______________________________________________________________________________________________________
_______________________________________________________________________________________________________
____________________________________________ ____________ _______________________________________ ____________
Administrator/Designee Signature
Date
Parent/Guardian Signature
Date
IEP Chairperson Name: ___________________________________________________________________________
Date Issues Clarified (Form A): _____________________
[Helpline Phone No. (213) 241-8135]
Date Helpline Contacted: ___________________ Specialist: _______________________________________
Process Filtered to:
Local School
Local District
DIS Hotline
Division
FAX to (213) 241-8917, with IEP and assessment report(s), after you have made Helpline contact.
For Division Office Use Only: Case Number _____________________
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