REQUEST FOR A FACILITATED IEP MEETING
NORTH DAKOTA DEPARTMENT OF PUBLIC INSTRUCTION
SPECIALLY DESIGNED SERVICES SFN 58305 (07/2017)
Student Name
*
First Name
Last Name
School District Information
School District/Special Education Unit
*
City
*
State
*
ZIP Code (ex. 58504-0440)
*
Name of Person Completing Form
*
Title of Person Completing Form
*
Phone Number
*
Please enter a valid phone number.
Parent/Guardian Name
*
Student’s Age
*
Grade
*
Cell Phone Number
*
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
Disability
*
In our last IEP team meeting, we reach an impasse regarding the following areas:
*
Placement
Identifiication/evaluation
Present levels of educational performance
Services
Transition
Goals (objective)
Adaptations/accommodations
Related Services
Assistive Technology
Progress Reporting
Discipline/Behavior
Implementation of IEP
Other (specify)
Other (specify)
The IEP Facilitation:
Is a voluntary process;
Uses a neutral third party;
Permits a guided IEP meeting;
Assists the IEP team members to communicate
effectively;
Supports all team members;
Provides an opportunity to identify new options
to address unresolved concer
ns.
The IEP Facilitator
Is neutral;
Is knowledgeable and experienced in the IEP process;
Participates only when invited by both parties, but is not a member of the IEP team;
Ensures that the meeting is student-focused;
Does not make decisions and does not tell the IEP team members how to solve issues;
Does not provide legal advice.
Signature of Parent/Guardian or Adult Student
Date
/
Month
/
Day
Year
Signature of District Administrator
Date
/
Month
/
Day
Year
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