Dispute Resolution Request Form Related to Special Education and CDEC Universal Preschool Programs

Date of Completion

mm/dd/yyyy

Name of Person Completing this Form

Title of Person Completing this Form

Email of Person Completing this Form

Phone Number of Person Completing this Form

Phone

Administrative Unit Name

Parties to the Dispute

Number of Parties to the Dispute

Name of LCO and/or Universal Preschool Provider

Name of Contact

Title of Contact

Phone Number of Contact

Phone

Email of Contact

Please describe the following:

The nature of the problem.

The specific date the problem began

mm/dd/yyyy

The relevant facts relating to the problem

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.

Please describe how this problem could be resolved

The complaint and all attachments have been shared with all other parties to the dispute.

Yes

Send me a copy of my responses

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