Bureau of Indian Education
State Complaint
THIS FORM IS NOT REQUIRED TO FILE A STATE COMPLAINT
AS LONG AS THE FORM OR DOCUMENT (i.e. LETTER) USED MEETS IDEA 2004 CONTENT REQUIREMENTS
A parent, an organization or an individual may file a complaint alleging a violation of the Individuals with Disabilities Education
Act (IDEA) 2004 and corresponding Federal regulations. The complaint must allege a violation that occurred not more than one
year prior to the date the complaint is received by the Bureau of Indian Education (BIE).
Date that serves as the basis of the request for this complaint:
/
/
Month /
Day / Year
*COMPLAINANT CONTACT INFORMATION
Name of person(s) or agency filing State Complaint:
Address:
Home/Cell Phone: (
)
Work Phone: (
)
E-Mail Address:
GENERAL INFORMATION
(Information applicable to a student specific complaint)
*Name of Student:
Gender: Female
Male
Date of Birth:
/
/
Month /
*Address of Student:
(If homeless, may use available contact information)
Age:
Day / Year
Grade:
Name of Parent/Guardian:
Home Number: (
)
-
Address of Parent/Guardian:
Work Number: (
)
-
*Name of School Student attends:
SUMMARY OF COMPLAINT
*Describe how the school has violated a required rule or law pertaining to IDEA 2004 (attach additional pages as necessary):
*Describe the facts on which the complaint is based (attach additional pages as necessary):
*Description of the nature of the problem of the student, including facts relating to the problem; required only if a student specific
complaint (attach additional pages as necessary):
*Briefly explain a proposed resolution to the problem if known; required only if a student specific complaint (attach additional
pages as necessary):
*Signature of person(s) or official of agency filing State Complaint
Date
Please contact the Bureau of Indian Education, Division of Performance and Accountability, Special Education at (505) 563-5264
for additional information. This State Complaint form or if using another document (i.e. letter) that document must be mailed,
faxed or hand-delivered to the school identified to be in alleged violation of IDEA 2004 requirement(s) and to:
Bureau of Indian Education
Division of Performance and Accountability
Attention: Supervisory Education Specialist – Special Education
1011 Indian School Rd, Suite 332
Albuquerque, NM 87104
Fax: (505) 563-5233
*IDEA 2004 Content Requirements (34 CFR §300.153)
Revision September 2010