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Sample Letters
PENNSYLVANIA DEPARTMENT OF EDUCATION
BUREAU OF SPECIAL EDUCATION
DIVISION OF REGIONAL REVIEW
CONSUMER COMPLAINT FORM
______________________________________________________________________________________
INFORMATION ABOUT PERSON FILING THIS COMPLAINT:
NAME:
DATE: _______________
ADDRESS:
PHONE:____________ HOME: ____________ WORK:
RELATIONSHIP TO CHILD: PARENT / ADVOCATE / ATTORNEY / OTHER
___________________
______________________________________________________________________________________
INFORMATION ABOUT THE CHILD:
NAME: AGE:
IS CHILD CURRENTLY IN SCHOOL? YES NO _____
WHERE IS CHILD'S CURRENT PROGRAM?
(NAME OF DISTRICT, IU, APS, PRRI, ETC.)
___________________________
SPECIAL EDUCATION REGULAR EDUCATION
______________________________________________________________________________________
USE THIS SPACE TO DESCRIBE BRIEFLY THE PROBLEM. (IF MORE SPACE IS
NEEDED, ATTACH ADDITIONAL SHEET; ATTACH COPIES OF ANY DOCUMENTS, SUCH AS
CHILD'S IEP YOU THINK ARE IMPORTANT FOR THIS COMPLAINT):
PLEASE RETURN ORIGINAL & COPY OF THIS FORM TO: PENNSYLVANIA DEPARTMENT
OF EDUCATION
cc: BUREAU OF SPECIAL EDUCATION
DIVISION OF REGIONAL REVIEW
333 MARKET STREET
HARRISBURG, PENNSYLVANIA 17126-0333
(717) 783-6913
____________________________________________________________________________________________________________
FOR PDE USE ONLY
DATE REC'D BY DRR ________________ REVIEWER ASSIGNED
_________________________ DATE: ________________
INTAKE
LOGGED/ENTERED__________________________________________________________
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