Dispute Resolution Request Form Related to Special Education and CDEC Universal Preschool Programs
Date of Completion
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Name of Person Completing this Form
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Title of Person Completing this Form
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Email of Person Completing this Form
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Phone Number of Person Completing this Form
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Phone
Administrative Unit Name
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Parties to the Dispute
Number of Parties to the Dispute
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Name of LCO and/or Universal Preschool Provider
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Name of Contact
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Title of Contact
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Phone Number of Contact
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Phone
Email of Contact
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Name of LCO and/or Universal Preschool Provider 2
Name of Contact 2
Title of Contact 2
Phone Number of Contact 2
Phone
Email of Contact 2
Name of LCO and/or Universal Preschool Provider 3
Name of Contact 3
Title of Contact 3
Phone Number of Contact 3
Phone
Email of Contact 3
Please describe the following:
The nature of the problem.
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The specific date the problem began
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The relevant facts relating to the problem
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Please describe how the parties have discussed and attempted to resolve the dispute at the local level prior to submitting this request for dispute resolution.
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Please describe how this problem could be resolved
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The complaint and all attachments have been shared with all other parties to the dispute.
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Yes
No
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