Form Gci-1050b Rapdf - Prior Written Notice
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1GCI-1050B RAPDF (4-16)
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
Arizona Early Intervention Program (AzEIP)
PRIOR WRITTEN NOTICE
Parent(s) Name:
Child’s Name:
Address (No., Street, City, State, ZIP)
As the parents of a child who is involved with the Arizona Early Intervention Program, you have protections under the Individuals
with Disabilities Education Act. These protections are found in the AzEIP booklet, which is provided to you with this notice. Prior
written notice is one such protection. It means that we will let you know ahead of time about certain changes that we want to make and
give you the chance to say “yes” or “no” to those changes. The following is the change(s) that is being proposed/refused and the
reason(s) for the change(s).
Propose
Refuse
Evaluate to determine AzEIP eligibility. You have the right to request an evaluation anytime during the screening process.
Identify your child as eligible for AzEIP
Initiate provision of early intervention services
Change in provision of early intervention services
Change (no longer eligible for AzEIP)
Other (specify):
Description of action(s):
Reasons for the action(s):
The family has been informed of their rights and safeguards and received a written description of those rights and safeguards.
The family has been informed of their rights and safeguards and has access to a written description of those rights and
safeguards.
Notice was:
handed or
sent to the
parent/responsible party
Date:
Please contact me as soon as possible if you have any questions about this action or your procedural safeguards.
Name
Program
Phone No.
Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the Americans
with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and Title II
of the Genetic Information Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimination in admissions, programs,
services, activities, or employment based on race, color, religion, sex, national origin, age, disability, genetics and retaliation. The
Department must make a reasonable accommodation to allow a person with a disability to take part in a program, service or activity.
For example, this means if necessary, the Department must provide sign language interpreters for people who are deaf, a wheelchair
accessible location, or enlarged print materials. It also means that the Department will take any other reasonable action that allows you
to take part in and understand a program or activity, including making reasonable changes to an activity. If you believe that you will
not be able to understand or take part in a program or activity because of your disability, please let us know of your disability needs in
advance if at all possible. To request this document in alternative format or for further information about this policy, contact your local
office; TTY/TDD Services: 7-1-1. • Free language assistance for DES services is available upon request. • Disponible en español en
línea o en la oficina local.
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