ࡱ> hkg Ibjbj X||f%&&&8^,&;>" 4A;;;;;;;$=F@;;i;;;&&&;&;&&c5|6`8:v 5;;0;5@u"Z@$66&@7&;;;;&;@ : Florida Department of Education Bureau of Exceptional Education and Student Services State Complaint Form This form is to be used for filing a formal state complaint with the Florida Department of Education, when alleging that the school district has violated the educational rights of a student with a disability, under the Individuals with Disabilities Education Act (IDEA 2004) and corresponding state requirements. This form is also used for filing a state complaint for a violation of the educational rights of students who are gifted, according to state requirements. * Required Fields Please print Date:  FORMTEXT   / FORMTEXT   / FORMTEXT      * Name of Individual or Organization Filing the Complaint:  FORMTEXT       * Street Address:  FORMTEXT       * City:  FORMTEXT       * State:  FORMTEXT       *Zip Code:  FORMTEXT       * Home Telephone #:  FORMTEXT    - FORMTEXT    - FORMTEXT      Cell #:  FORMTEXT    - FORMTEXT    - FORMTEXT      Work #:  FORMTEXT    - FORMTEXT    - FORMTEXT      Email Address:  FORMTEXT        FORMCHECKBOX  Check here to receive correspondence via email. By checking this box, you are giving the bureau permission to send all correspondence and reports by electronic mail to the email address identified above. All electronic mail will be sent password protected. Best Time to Reach you during the Day:  FORMTEXT       * Student s Name:  FORMTEXT       * Student s Street Address:  FORMTEXT       * City:  FORMTEXT       * State:  FORMTEXT       *Zip Code:  FORMTEXT       Student s Age:  FORMTEXT       Student s Grade:  FORMTEXT       * Student s Exceptionality:  FORMTEXT       * Your Relationship to the Student:  FORMTEXT       * School Name:  FORMTEXT       * School District:  FORMTEXT       * State Complaint: I am alleging that *  FORMTEXT       school district, has violated federal or state requirements regarding the education of a student with a disability or a gifted student. I understand I must include the facts that support my allegation(s). I also understand that the complaint must allege a violation that occurred not more than one year prior to the date that the complaint is received by the Bureau. * These are the facts that lead me to believe that there has been a violation of exceptional student education laws.  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FORMTEXT        FORMCHECKBOX  Check here if you have included any attachments. I understand I will be contacted by the bureau staff assigned to my case to: Advise me of my rights to alternative resolution activities such as early resolution or mediation Clarify and review my complaint facts Request submission of additional information or documentation to support my statement (if needed) ___________________________________________  FORMTEXT   / FORMTEXT   / FORMTEXT      * Signature of Complainant * Date Please forward this complaint form to your exceptional student education (ESE) school district office AND via email, fax or mail to the Bureau of Exceptional Education and Student Services: Email:  HYPERLINK "mailto:BEESScomplaints@fldoe.org" BEESScomplaints@fldoe.org Fax: 850-245-0953 Mail: Renee Jenkins, Senior Educational Program Director Florida Department of Education Bureau of Exceptional Education and Student Services 325 West Gaines Street, Suite 614 Tallahassee, FL 32399-0400 Please call 850-245-0475 if you have any questions.     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