"Complaint Form" - Ohio

Complaint Form is a legal document that was released by the Ohio Department of Education - a government authority operating within Ohio.

Form Details:

  • Released on August 1, 2009;
  • The latest edition currently provided by the Ohio Department of Education;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Ohio Department of Education.

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Office for Exceptional Children
Attn: Assistant Director of Procedural Safeguards
nd
25 South Front Street, 2
Floor, MS 202
Columbus, OH 43215
COMPLAINT FORM
Complainant Name:
Complainant Relationship to Student:
Complainant Address:
City, State and Zip Code:
Complainant Phone Numbers:
Work:
Home:
Email Address (Optional):
Student’s Name:
Student’s Address (if address is different from complainant’s address):
Student’s Age:
Student’s Grade Level:
Student’s Area of Identified/Suspected Disability:
Student’s School District Of Residence:
Name Of The School The Student Is Attending:
_____ Please check if your child participates in the Autism Scholarship Program
Complaint Form, Revised August 2009
Page | 1
Office for Exceptional Children
Attn: Assistant Director of Procedural Safeguards
nd
25 South Front Street, 2
Floor, MS 202
Columbus, OH 43215
COMPLAINT FORM
Complainant Name:
Complainant Relationship to Student:
Complainant Address:
City, State and Zip Code:
Complainant Phone Numbers:
Work:
Home:
Email Address (Optional):
Student’s Name:
Student’s Address (if address is different from complainant’s address):
Student’s Age:
Student’s Grade Level:
Student’s Area of Identified/Suspected Disability:
Student’s School District Of Residence:
Name Of The School The Student Is Attending:
_____ Please check if your child participates in the Autism Scholarship Program
Complaint Form, Revised August 2009
Page | 1
A description of the problem including facts relating to the problem:
Date of violation:
*As per 34 C.F.R. §300.153(c) [Filing a complaint], the date of the alleged violation cannot be more than
one year prior to the date that you are filing this complaint.
A proposed resolution to the problem:
*The proposed resolution will be taken into consideration; however, the final resolution of the complaint will
be determined by the Ohio Department of Education Office for Exceptional Children.
Complaint Form, Revised August 2009
Page | 2
A description of the problem including facts relating to the problem:
Date of violation:
*As per 34 C.F.R. §300.153(c) [Filing a complaint], the date of the alleged violation cannot be more than
one year prior to the date that you are filing this complaint.
A proposed resolution to the problem:
*The proposed resolution will be taken into consideration; however, the final resolution of the complaint will
be determined by the Ohio Department of Education Office for Exceptional Children.
Complaint Form, Revised August 2009
Page | 3
A description of the problem including facts relating to the problem:
Date of violation:
*As per 34 C.F.R. §300.153(c) [Filing a complaint], the date of the alleged violation cannot be more than
one year prior to the date that you are filing this complaint.
A proposed resolution to the problem:
*The proposed resolution will be taken into consideration; however, the final resolution of the complaint will
be determined by the Ohio Department of Education Office for Exceptional Children.
Complaint Form, Revised August 2009
Page | 4
A description of the problem including facts relating to the problem:
Date of violation:
*As per 34 C.F.R. §300.153(c) [Filing a complaint], the date of the alleged violation cannot be more than
one year prior to the date that you are filing this complaint.
A proposed resolution to the problem:
*The proposed resolution will be taken into consideration; however, the final resolution of the complaint will
be determined by the Ohio Department of Education Office for Exceptional Children.
Complaint Form, Revised August 2009
Page | 5