PRIOR WRITTEN NOTICE

 

This form is provided to parents prior to the district initiating or refusing to change the identification, evaluation, educational or placement or provision of a free appropriate public education.

 

·        Fill out student name and date of birth.

 

·         If the district is proposing to do something, check the box “Proposal to initiate or change” and then check the appropriate box that applies to the situation that has required a Prior Written Notice.

 

·         If the district is refusing a request made by the parent, check the corresponding box and then check the box that applies to the situation that has required a Prior Written Notice.

 

·         Description of proposed or refused action: Briefly describe the proposed action or the action that the district is refusing to take.

 

·         Reason(s) for proposed or refused action: Note the specific reasons why the district is refusing to take a proposed action or a refused action.

 

·         Description of evaluation procedures, tests, records, or reports used in deciding to propose or refuse this action: Document the procedures that the district used in making the determination to propose or refuse an action.

 

·         Description of other options considered and reasons for rejecting them: Document other options that were considered and the reasons for rejecting the options.

 

·         Other factors relevant to the proposal or refusal: Document any other factors that were relevant to the district’s decision to propose or refuse to do an action.

 

·         Print name of district contact, position, phone and email address.

 

 

 

[Excerpted from the State SELPA IEP Manual, July 2009. For the 2008-2009 form set.]