Prior Written Notice

Date: Enter Today’s Date	Student Name: Enter Student’s Full Name

Birthdate: Enter Student’s Date of Birth Parent(s)/Guardian(s): Enter Names(s) of Parent(s)

The school district must give you a written notice (information received in writing), whenever the school district:

(1) Proposes to begin or change the identification, evaluation, or educational placement of your child or the provision of a free appropriate public education (FAPE) to your child; or

(2) Refuses to begin or change the identification, evaluation, or educational placement of your child or the provision of FAPE to your child.

The school district must also provide the notice in a language that is understandable to you.

Note: This notice may also be used when a Revocation of Consent or other request has been

received by the school district from you or your adult student.

1. Description of the action that the school district proposes or refuses to take: Enter a description of the action that the school district proposes or refuses to take.

2. Explanation of why the school district is proposing or refusing to take that action: Enter an explanation of why the school district is proposing or refusing to take that action.

3. Description of each evaluation procedure, assessment, record, or report the school district used in deciding to propose or refuse the action: Enter a description of each evaluation procedure, assessment, record, or report the school district used in deciding to propose or refuse the action.

4. Description of any other options that the Individualized Education Program (IEP) Team considered and the reasons why those options were rejected: Enter a description of any other choices that the Individualized Education Program (IEP) team considered and the reasons why those choices were rejected.

5. Description of other factors that are relevant to why the school district proposed or refused the action: Enter a description of other reasons why the school district proposed or refused the action.

If this proposed action is a change in identification, evaluation, placement of the child or the provision of FAPE to the child, when will this action be implemented? Date: Enter the date this change will be implemented.

You and your child have protections identified in the Parental Rights (also called procedural safeguards). If you need a copy of those procedural safeguards, need assistance in understanding your rights, or need documents translated into another language, please contact the following:

Enter Name & Position of Contact	Enter contact’s Phone Number Enter Contacts Email Address

Name & Position Phone Number	Email