NYSED NavigationNYSED HOME •  SEARCH TOPICS A-ZCONTACT NYSED
 

Vocational and Educational Services for Individuals with Disabilities (VESID)
Special Education and Vocational Rehabilitation Services


Available in Word or PDF Format for Printing                                  

               

New York State Education Department

Sample State Complaint Form

 

          If a parent, individual or organization believes that a school district or public agency (such as a Board of Cooperative Educational Services (BOCES), charter school or school operated by a State agency) has violated a requirement of Part B of the Individuals with Disabilities Education Act (IDEA) or State law/regulation related to the education of students with disabilities, they may submit a written, signed State complaint to the New York State Education Department (NYSED. Attached is a New York State (NYS) Sample Complaint Form that may be used to submit a complaint. Use of this form is not required.  However, if using your own format to submit a State complaint, you must provide the required information, as appropriate, as indicated on the sample form. Upon receipt of a written complaint by an individual or agency, NYSED must determine if the alleged violation occurred and issue a written decision of its findings.

 

          NYSED encourages parents and school districts to use mediation to resolve complaints regarding the education of a student with a disability.

 

Parent, Individual or Organization (Complainant) Submitting the State Complaint 

  • the name and address of the residence of the child;

  • the name of the school the child is attending;

  • in the case of a homeless child or youth, available contact information for the child and the name of the school the child is attending;

  • a description of the nature of the problem of the child (the concerns that led you to file the complaint), including the facts relating to the problem; and

  • a proposed resolution of the problem to the extent known and available at the time the person is filing the complaint.


State Complaint Procedures

 

Instructions:  Complete, sign and make two copies of the original State complaint form.

  • Send the original State complaint form to NYSED, Office of Vocational and Educational Services for Individuals with Disabilities (VESID), Room 1623, One Commerce Plaza, Albany, NY  12234.  Attention:  State Complaints.

  • Send one copy of the State complaint form to the Board of Education or Trustees of the school district serving the child at the same time that the complaint is filed with NYSED.

  • Retain a copy of the State complaint form for your records

 

 


 


 

SAMPLE NEW YORK STATE COMPLAINT FORM

 

The following sample form may be used to file a State complaint. 

I. Complainant Contact Information

 

Name of Parent, Individual or Organization filing the complaint:

 

Date:

Check one:

Parent or Person in Parental Relationship

Surrogate Parent

Parents’ Attorney

School District/State Agency Representative

School District/State Agency Attorney

Other                                                  

Signature:
Yes, I forwarded a copy of the State complaint to the school district or public agency

Mailing Address of Parent, Individual or Organization:

 

Telephone:

 

II. Child-specific Information

 

 

Child’s Name:

 

Date of Birth:

Address of the Residence of the Child (if any):


 

Name/Address of the School the Child is Attending:

 

Additional Contact Information for Homeless Child or Youth, if available:

 

III. School Information

 

 

 

Name of School District (or Public Agency) Responsible for the Provision of Services:

 

 

School Representative or Contact (if known):


 

Address:

IV. Complaint Information –

Alleged Violation is Child-specific

 

 

 

Describe the nature of the problem of the child (the concerns that led you to file this complaint), including facts relating to the problem.  Attach additional pages or documents as necessary.

 

 

 

 

State your proposed resolution of the problem to the extent known and available at this time.  Attach additional pages or documents as necessary.

 

 

 

 

V. Complaint Information –

Alleged Violation is Systemic

(e.g., inappropriate school procedures and/or practices)

 

 

 

Statement that the school district or public agency has violated Part B of IDEA or a State law/regulation related to the education of students with disabilities.

 

 

 

 

Description of the facts on which the above statement is based: