Illinois State Board of Education (ISBE), Special Education Services Division

STATE-SPONSORED MEDIATION ELECTRONIC REQUEST FORM

Instructions: Mediation is a voluntary process that requires the agreement of both the parent and school district to participate.  Requests may be initiated by either the district or parent/guardian/surrogate/adult student.

Please provide the following information in order to initiate a request for Mediation.  Unknown or not applicable sections should be marked as such. Requests may be submitted via U.S. Mail, Email, or Fax.

● = Required field.

Student Information               

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First Name	●
Last Name	●
Date of Birth *	(mm/dd/yyyy) ●
Gender	Select... Female Male Non-Binary ●
Attendance Center

Disability Category(IES)                 (check all that apply)   

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AutismEmotional DisabilityOrthopedic ImpairmentTraumatic Brain Injury
Deaf-BlindnessHearing ImpairmentOther Health ImpairmentVisual Impairment
DeafnessIntellectual DisabilitySpecific Learning DisabilitiesUnknown/None
Developmental DelayMultiple DisabilitiesSpeech/Language Impairment

Parent Information               

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First Name      ●
Last Name      ●
Address Line 1 ● Address Line 2 Suite/Apt. City ● State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming ● Zip Code ●	Best Daytime Phone Select... Business Home Mobile Fax ● Business Phone Business phone number extension Ext. Home Phone Mobile Phone Fax E‑Mail E‑Mail (2)

School District Information               

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District Name Phone Number Email District Contact First Name Last Name

Address Line 1 Address Line 2 Suite/Apt. City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code

Description of the Issue(s)               

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Narrative of Issues ●


Requestor Information               

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Submit               

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