Administrative Review / Mediation / Impartial Hearing Request

VES-711 (3/03)

Preferred form of submittal is VES-711 in PDF.

The University of the State of New York
THE STATE EDUCATION DEPARTMENT
Office of Vocational and Educational Services for Individuals with Disabilities (VESID)

YOUR NAME

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PHONE (Include Area Code)

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YOUR ADDRESS
Street (Include Building Or Apartment Number, As Applicable)

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City

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State

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Zip

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_ I agree to delay the scheduling of the Impartial Hearing until an Administrative Review is completed.

_ I agree to delay the scheduling of the Impartial Hearing until Mediation is completed.

-OR

I would like the following to be completed within 60 days:

_ Administrative Review.
_ Mediation
_ Impartial Hearing only, I do not want an Administrative Review or Mediation.

I understand that I can request an Administrative Review and/or Mediation first, or instead, go directly to an Impartial Hearing. I understand that no matter which option I choose, all timeframes will begin from the date when VESID receives this signed request. All parties must agree to any extended timeframes. Information about Administrative Review, Mediation and Impartial Hearing is included in the brochure " What can I do if I disagree with VESID's decision about my case."

What are the issues you would like reviewed? What action would you like from VESID? As simply as you can, describe the problem, when it happened, and identify the people involved. (Need more space? Use the reverse or attach a page.)

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SIGN AND DATE THE FORM: (to begin your due process)

Your Signature

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Date

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If you intend to be represented by a relative, an attorney, an advocate, or another spokesperson, please complete the following required information so that notice of the hearing and other documents can be provided to your representative.

NAME

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RELATIONSHIP TO YOU

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STREET ADDRESS

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CITY

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STATE

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ZIP

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PHONE NUMBER (Include Area Code)

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The State Education Department does not discriminate on the basis of age, color, religion, creed, disability, marital status, veteran status, national origin, race, gender, genetic predisposition or carrier status, or sexual orientation in its educational programs, services, and activities. Inquiries concerning this policy of nondiscrimination should be directed to the Department's Office for Diversity, Ethics, and Access, Room 152, Education Building, Albany, NY 12234.

District Office:

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Date Received:

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