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

STATE-SPONSORED IEP FACILITATION ELECTRONIC REQUEST FORM

The facilitated Individualized Education Program (IEP) meeting is a voluntary process that requires the agreement of both the parent and school district to participate.  Ideally, request forms should be completed jointly by the district and parent/adult student; however, the State Coordinator can assist with the process if either party has difficulty speaking with the other party.  Prior to completing the request form, please be sure to provide at least a two week notice prior to any already scheduled IEP meeting.  This allows time for the State Coordinator to communicate with both parties, as well as, provides the facilitator adequate time to prepare an agenda for the scheduled meeting.  Without enough notice, your request may be declined.

Please provide the following information in order to initiate a request for a facilitated IEP meeting.  Unknown or not applicable sections should be left blank.  Your request will be reviewed by the State Coordinator and, if all necessary criteria are met, a neutral facilitator will be assigned to the case and will contact both parties.  The facilitator’s role is to support all parties’ full participation in the IEP meeting, keep IEP team members on task, clarify points of agreement and/or disagreement, and provide team members opportunities to consider alternative solutions.

● = 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

Disabilities                 (check all that apply)   

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Autism	Emotional Disability	Orthopedic Impairment	Traumatic Brain Injury
Deaf-Blindness	Hearing Impairment	Other Health Impairment	Visual Impairment
Deafness	Intellectual Disability	Specific Learning Disabilities	Unknown/None
Developmental Delay	Multiple Disabilities	Speech/Language Impairment

Languages Spoken by Student and Parent       show more           (check all that apply)   

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English	Cantonese (Chinese)	Japanese	Russian
American Sign Language	French	Korean	Tagalog (Filipino)
Spanish	German	Mandarin (Chinese)	Vietnamese
Arabic	Italian	Polish

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    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 Concern(s)               

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  Identify the concerns you have about the IEP meeting  (Check all that apply)






IEP Facilitation Meeting Type               

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  OPTIONAL: What type of IEP meeting are you requesting to be facilitated?  (check all that apply or skip if you do not know)

Review of Existing Data	Manifestation Determination
Initial Eligibility	Secondary Transition
Initial IEP	Graduation
Reevaluation	Termination of Placement
IEP Review/Revision	Functional Behavioral Assessment (FBA) / Behavior Intervention Plan (BIP)

(Please note that ISBE will attempt to work with the parties to preserve scheduled dates for IEP meetings but cannot guarantee a Facilitator will be able to attend the scheduled meeting date. The parties should be prepared to reschedule the IEP meeting depending upon the availability of the parties and the Facilitator as long as the date continues to meet regulatory timelines.)

Scheduled IEP Meeting               

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IEP meeting is currently scheduled?      Select... Yes No ●

IEP Facilitation Request               

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Have both parties agreed to a facilitated IEP meeting?      Select... Yes No ●

Identify your role      Select... Adult Student District Attorney District Employee Parent Parent Advocate Parent Attorney ●

Submit               

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