Prior Notice of Special Education Action
Date:		
	mm/dd/yy	

Dear:	Mr. and Mrs. Parent				,

This notice informs you of the following action:
Per parent request, the District will discontinue special education and related services for STUDENT on DATE (10 school days from receipt or “date agreed upon by parent”), because the parent revoked consent for special education.

which is a   proposal  or   refusal              to               initiate  or   change
	
the following aspect of 		STUDENT	‘s special education:	
	
 Identification 	
 Placement (other than initial placement)
 Provision of a free, appropriate public education (includes IEP)	

This action is proposed because: the parent revoked consent for the District to continue providing special education and related services to the student.	
	
This action is based on the following evaluation procedures, tests, records or reports:   This change of placement is based solely on the parents’ revocation of consent for the provision of special education and related services.	
	
Other options we considered were:  continuing to provide the student with special education and related services in the student’s current setting.	
	
We rejected these options because: the District is required by law to discontinue special education and related services upon written revocation of parental consent for these services.  The parents provided a written revocation of consent to the District on DATE.	
	
Any other factors considered by the team:  The parent was informed of the following –	
o	The revocation of consent will have the effect of returning the student to general education as a nondisabled student; no special education supports will be provided.
o	The student will have access to educational programs and standard accommodations, if any, that are available to other students in the general education setting.
o	The District will no longer be obligated to provide the student with a FAPE, conduct a three-year reevaluation, or hold an annual IEP meeting.
o	The student will not automatically be considered eligible for services under § 504 of the Rehabilitation Act.
o	The student will be subject to general education disciplinary procedures; the District will not be required to determine that the conduct of a student was not a manifestation of the student’s disability before taking disciplinary action.
o	The District will continue to fulfill its “child find” obligations, detailed in OAR 581-015-2080 and -2085, with regard to the student.
o	The District will not be required to remove all documentation indicating the student’s prior eligibility for and enrollment in special education services.	

Sincerely, 

Name/Title 					

Phone       						

Parents of a child with a disability have protection under procedural safeguards.  For a copy of the Procedural Safeguards or for assistance in understanding this information you may contact:	

														
		Name						Title				Phone	

Prior Notice of Special Education Action

This form is used to:

•	Meet the requirement to notify parents before the program takes any action with regard to a student’s identification, evaluation, placement, individualized education plan, or provision of a free, appropriate public education.

•	Provide documentation of specific changes to be made and the timing for those changes.

•	Citations: 20 USC § 1415(b); 34 CFR 300.503; OAR 581-015-2310.

Directions:

1.	Enter the month, day, and year the form is completed.

2.	Enter the name of the parent, guardian, or surrogate parent.

3.	Describe the action the team is proposing.

4.	Check the box(s) that are pertinent to the actions that are proposed.

5.	Enter the student’s name.  

6.	Check the box(s) that are pertinent to the actions that are proposed.

7.	Describe why the team is proposing or refusing this action.

8.	Describe any evaluation procedures, tests, records, and reports used to make this decision.

9.	Describe the options that the team considered prior to this action.

10.	Explain why the options were rejected.

11.	Describe any other factors that contributed to the decision.

12.	Enter the name, title, and phone number of the person to contact to obtain a copy of the Procedural Safeguards.