MEDIATION REQUEST FORM FOR SPECIAL EDUCATION DEPARTMENT - ISBE 34-15 - Request for state-sponsored mediation

Oct 10, 2026

Uploaded by Margaret

Mediation Request Form for the Illinois State Board of Education Special Education Department collects party consent information and details needed to initiate state-sponsored mediation. The form explains mediation is voluntary and requires agreement by both the parent and the school district, and it allows submission by mail, email, or fax. Sections gather student, parent, school district, requestor role, disability categories, issue description, and relevant contact and legal representative information, including required dates and acknowledgements.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages2

Reading Time5 min

AccessFree to download

Section I – Student Information

Section II – Parent Information

Section III – School District Information

Section IV – Description of the Issue(s)

Section V – Requestor Information

MEDIATION REQUEST FORM FOR SPECIAL EDUCATION DEPARTMENT 100 North First Street, N-253 Springfield, Illinois 62777-0001 SPECIAL EDUCATION DEPARTMENT 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 parent/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. This completed form should be submitted to: Mediation Coordinator Illinois State Board of Education Special Education Department 100 North First Street, N-253 Springfield, IL 62777-0001 Fax: (217) 782-0372 Email: [statemediation@isbe.net](statemediation@isbe.net) Telephone assistance: (217) 782-5589 or (866) 262-6663 TTY/TDD: (217) 782-1900 | SECTION I – STUDENT INFORMATION | | | | --- | --- | --- | | STUDENT FIRST NAME | STUDENT LAST NAME | DATE OF BIRTH (mm/dd/yyyy) | DISABILITY CATEGORY(IES) : (Check all that apply) Autism Deafness Deafness-Blindness Developmental Delay Emotional Disability Hearing Impairment Intellectual Disability Multiple Disabilities Orthopedic Impairment Other Health Impairment Speech Language Impairment Specific Learning Disability Traumatic Brain Injury Visual Impairment Unknown | SECTION II – PARENT INFORMATION | | | | | | | | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | | | | | | | | | | | | PARENT/GUARDIAN/SURROGATE PARENT NAME | DAY TELEPHONE (Include Area Code) Home Work | | | | | | | Cell | | | | | | | | | | | | ADDRESS (Street, City, State, ZIP Code) | | EMAIL | | | | | | | | NAME OF PARENT’S ATTORNEY/ADVOCATE (If applicable) | TELEPHONE (Include Area Code) | | | | | | | | | ADDRESS (Street, City, State, ZIP Code) | | EMAIL | | | | | | | ISBE 34-15 (9/25) Page 1 of 2 | SECTION III – SCHOOL DISTRICT INFORMATION | | | --- | --- | | DISTRICT NAME AND NUMBER | TELEPHONE (Include Area Code) | | ADDRESS (Street, City, State, ZIP Code) | EMAIL | | PRIMARY DISTRICT CONTACT NAME/TITLE | TELEPHONE (Include Area Code) | | ADDRESS (Street, City, State, ZIP Code) (If different from district) | EMAIL | | NAME OF DISTRICT ATTORNEY (If applicable) | TELEPHONE (Include Area Code) | | ADDRESS (Street, City, State, ZIP Code) | EMAIL | SECTION IV – DESCRIPTION OF THE ISSUE(S) Brief description of the dispute and the resolution you are seeking: (Do not go beyond space provided. Submit additional pages if necessary.) | SECTION V – REQUESTOR INFORMATION | | | | | | | | | | | | | | | | | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | | | | | | | | | DAY TELEPHONE (Include Area Code) Home Work | | | | | | | | | | | NAME OF PERSON COMPLETING THIS FORM | | | | | | | | | | | | | | | | | Cell | | | | | | | | | | | | | | | | | | | | | EMAIL | | | | | | | | | | | | | | | | | | | IDENTIFY YOUR ROLE: | | | | | | | Parent’s Advocate | | | Parent’s Attorney | | | District | | District’s Attorney | | | | | Parent/Guardian/Surrogate Parent | | | Adult Student | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | Have both parties agreed to state-sponsored mediation? | | | | | | | Yes No | | | | | | | | | | | | Date mediation request completed/submitted to the Illinois State Board of Education: | | | | | | | | | | | | | | | | | | ISBE 34-15 (9/25) Page 2 of 2 Print Reset Form

FAQs

What is the purpose of this mediation request form?

It initiates a request for state-sponsored mediation by collecting the information needed to start the process for special education disputes.

Who can submit a mediation request?

Either the school district or the parent/guardian/surrogate parent/adult student may initiate the request.

How should the form be submitted to the Illinois State Board of Education?

The completed form can be submitted via U.S. Mail, email, or fax to the Mediation Coordinator, ISBE Special Education Department.

Oct 10, 2026

Uploaded by Margaret