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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 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
Requests for a State complaint must be made in writing.
The State complaint must include:
State Complaint Procedures
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Instructions: Complete, sign and make two copies of the original State complaint form.
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SAMPLE NEW YORK STATE COMPLAINT FORM
The following sample form may be used to file a State complaint.
If alleging violations with respect to a specific child, you must complete Sections I. Complainant Contact Information, II. Child-specific Information, III. School Information and IV. Complainant Information (Alleged Violation is Child-specific).
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I. Complainant Contact Information |
Name of Parent, Individual or Organization filing the complaint: | Date: |
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Check one:
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Signature: | |
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Mailing Address of Parent, Individual or Organization: |
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| Telephone: | ||
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II. Child-specific Information
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Child’s Name: | Date of Birth: |
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Address of the Residence of the Child (if any):
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| Name/Address of the School the Child is Attending: | ||
| Additional Contact Information for Homeless Child or Youth, if available: | ||
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III. School Information
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Name of School District (or Public Agency) Responsible for the Provision of Services:
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School Representative or Contact (if known):
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Address: | |
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IV. Complaint Information – Alleged Violation is Child-specific
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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.
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State your proposed resolution of the problem to the extent known and available at this time. Attach additional pages or documents as necessary.
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V. Complaint Information – Alleged Violation is Systemic (e.g., inappropriate school procedures and/or practices)
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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.
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Description of the facts on which the above statement is based:
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