Missouri Department of Elementary and Secondary Education

MISSOURI DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION
SPECIAL EDUCATION – COMPLIANCE

CHILD COMPLAINT-MODEL FORM 

Directions

The party filing the complaint must forward a copy of the complaint to the public agency/school district serving the child at the same time the party files the complaint with the DESE. The violation must have occurred not more than one year prior to the date the complaint is received by the DESE. 

MAIL completed form to:     Missouri Department of Elementary and Secondary Education (DESE)
                                        Division of Special Education Compliance       
                                        C/O Child Complaint Coordinator
                                        Post Office Box 480
                                        Jefferson City, MO 65102-0480

Or FAX to:                         (FAX) 573-526-4404  
 

Contact Information

Agency/District Name

County
 

School of Attendance

Child’s Name

Disability (if known)

Age

Grade
 

Address

Is Child Homeless?   Y    N      If yes, other contact information:

City, State, & Zip

Parent/Guardian Name:

Person filing the complaint (if different than Parent/Guardian)

Address:

Address:

City, State, & Zip:

City, State, & Zip:

Phone:  Home

Phone:  Home

Work

Work

Other (mobile phone and/or email address) 

Relationship to Child:

The agency/district indicated above has violated state and federal regulations implementing the IDEA in the following area(s):

__Placement         __  Evaluation      __Related Services             __IEP     __Due Process
__FERPA              __Discipline          __Other (Explain)

Rev. 10/13/06