Waiver of Written Translation in Primary Language of Prior Written Notices (PWN)
Student Name:
School:
Parent Name(s):
Date:
Student Number:
Parent’s Primary Language:
Name of Evaluation or IEP Case Manager:
Name of Interpreter Who Orally Interpreted Offer of Written Translation:
Date of Offer of Written Translation:
Form of Contact with Parent (e.g., in person, telephone, etc.):
I was offered a written translation in my primary language of Prior Written Notice (PWN) consent forms. I am declining that offer
and waive my right to have a written translation of such Notices.
_____ I require oral interpretation of the PWN consent forms in my primary or native language.
OR
_____ I do not require oral interpretation or the PWN consent forms translated into my primary or native language.
I understand that this waiver of written translation in my primary language of PWNs will remain in effect unless withdrawn by me in
writing or by contacting my child’s Individualized Education Program (IEP) case manager.
______________________________________________
Signature of Parent/Guardian/Student 18 years and older
___________________
Date
______________________________________________
Signature of IEP Case Manager
___________________
Date
Copies:
Special education file
Parent/Guardian