Form Pi-2117 - Idea Complaint Form printable pdf download

Form Pi-2117 - Idea Complaint Form

Wisconsin Feem Kev Cob Qhia Pej Xeem

COV KEV QHIA UA: Ua 3 daim. Khaws ib daim rau koj tau saib. Muab ib

daim rau Tsoom Fwv Tsev Kawm Ntawv pov plob rau tus me nyuam txoj

XEEV TSAB CAI IDEA DAIM FOOS TSIS

kev kawm. Muab daim foos rheev npe xa mus rau:

TXAUS SIAB

CAROLYN STANFORD TAYLOR

PI-2117 (Rev. 12-09)

WISCONSIN DEPARTMENT OF PUBLIC INSTRUCTION

Kee los ntawm tsab Cai IDEA2004, 34 CFR 300.151-

P. O. BOX 7841

153, 300.509. Kev siv daim foos no yog kev tuaj yeem.

MADISON, WI. 53707-7841

Daim foos no tau tsim los pab cov niam txiv teev xeev tsab cai IDEA daim foos tsis txaus siab. Yuav tau teev txhua yam ntsiab lus. Yog tias tsis teev

txhua yam yuav theem qhov kev soj ntsuam kev tsis txaus siab. Feem saib xyuas koj tsab ntawv teev kev tsis txaus siab mam hais tuaj rau ko.

Tus Case No. Tau Muab Rau

Hnub Ua Kom Tiav (Date Due)

Hnub Tau Txais (Date Received)

FOR

DPI

USE

I. TXHUA YAM NTSIAB LUS

Tus Tsis Txaus Siab Lub Npe

Kev Txheeb Ze Rau Tus Me Nyuam

Chaw Nyob Txoj Kev, Nroog, Xeev, ZIP

Tus Xov Tooj Area/No.

Tus Me Nyuam Lub Npe

*Qhov Chaw Nyob ntawm Tus Me Nyuam Nyob Txoj Kev, Nroog, Xeev, Zip

Cheeb Tsam Tsev Kawm Ntawv Ntawm Tus Me Nyuam Nyob

Cheeb Tsam Tsev Kawm Ntawv Tus Me Nyuam Kawm

Piav qhov teeb meem tus me nyuam muaj cuam tshuam rau tes hauj lwm tau plov meej ntawd, xws li tej ntsiab lus hais txog qhov teeb meem. Teev

qhov cheeb tsam tsev kawm ntawv (los yog lwm lub tsev kawm txuj) tau yuam xeev los yog tsoom nom tswv fab kev kawm tshwj xeeb txoj cai. Teev

hnub qhov kev yuam cai tau tshwm sim rau tib si. Teev tej ntsiab lus uas yuav pab txhawb tau nqe lus saum no. Siv ib daim ntawv ntxiv los yog siv sab

tom qab yog tsis txaus sau.

Lub ntsiab lus xaus ntawm qhov teeb meem uas tau plov meej (yog tias paub thiab muaj rau cov niam txiv lub sij hawm no). Siv ib daim ntawv ntxiv los

yog siv sab tom qab yog tsis txaus sau.

II. MEM TES RHEEV NPE

Tus Neeg Tsis Txaus Siab Tus Mem Tes Rheev Npe

Hnub Tau Rheev Npe



* Rau cov me nyuam tsis muaj vaj tsev nyob, muab xov tooj chaw nyob thiaj tau sib nug [34CFR 300.153 (b)(4)(iii); 300.508 (b)(4)]

Form Pi-2117 - Idea Complaint Form