NDDPI -REQUEST FOR STATE COMPLAINT INVESTIGATION

An individual or organization may file a State Complaint with the ND Department of Public Instruction (NDDPI), Office of Specially Designed Services if they believe a public agency has violated a state or federal special education law requirement. All State Complaints must be in writing, must be signed, and should identify the alleged violation(s). A complainant can file a State Complaint with the NDDPI within one (1) year of an alleged violation.

The NDDPI will ensure confidentiality, investigate the State Complaint, and issue a decision within sixty (60) calendar days of receiving the State Complaint unless exceptional circumstances extend this timeline. If the NDDPI finds that the public agency has violated requirements relating to special education, the local educational agency will be directed to complete corrective action(s) to correct the violation(s).

Complainant Contact Information

Date of Request

Date

Name of Complainant

Home Phone Number

Work Phone Number

Address

Complainant Address

Street Address Line 2

CityState

Zip Code

Cell Phone Number

Fax Number

Email Address

example@example.com

Child Contact Information

Child's Name

Date of Birth (optional)

Date

Child's Address (if different than that above)

Street Address

Street Address Line 2

CityState

Zip Code

School Child Attending

School Representative or Contact (optional)

District Child Attending (optional)

Complainant's Relationship to the Child (optional)

Contact information if the child is homeless

Would you consider mediation to resolve these issues?

YesNo

Please forward this State Complaint to the school district/public agency at the same time it is filled with NDDPI.

Date: I forwarded a copy of the State Complaint (e.g, Superintendent, Special Education Director)

Date

Name of person/title to whom you sent the State Complaint (e.g., Superintendent, Special Education Director)

State Complaint and Supporting Fact(s)

Directions: List each issue separately. Describe the violation and the specific facts related to that violation. If possible, include dates, names and locations. Attach additional pages if more space is needed.

Proposed Solution(s)

Directions: Describe what remedies have been or could be attempted to correct the problem. Attach additional pages if more space is needed.

0/800

Signature (NDDPI will accept an electronic signature)

Date