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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.",{"@graph":69,"@context":122},[70,84,105],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":35,"@type":76,"position":81},"https://docshare.wps.com/document/healthcare/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/mediation-request-form-for-special-education-department-isbe-34-15-request-for-state-sponsored-mediation/534792/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":99,"encodingFormat":97,"isAccessibleForFree":100,"interactionStatistic":101},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/mediation-request-form-for-special-education-department-isbe-34-15-request-for-state-sponsored-mediation/534792.png","ImageObject",300,407,{"name":92,"@type":93},"Margaret","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-11-10","2026-10-10",true,{"@type":102,"interactionType":103,"userInteractionCount":52},"InteractionCounter",{"@type":104},"ViewAction",{"@type":106,"mainEntity":107},"FAQPage",[108,114,118],{"name":109,"@type":110,"acceptedAnswer":111},"What is the purpose of this mediation request form?","Question",{"text":112,"@type":113},"It initiates a request for state-sponsored mediation by collecting the information needed to start the process for special education disputes.","Answer",{"name":115,"@type":110,"acceptedAnswer":116},"Who can submit a mediation request?",{"text":117,"@type":113},"Either the school district or the parent/guardian/surrogate parent/adult student may initiate the request.",{"name":119,"@type":110,"acceptedAnswer":120},"How should the form be submitted to the Illinois State Board of Education?",{"text":121,"@type":113},"The completed form can be submitted via U.S. Mail, email, or fax to the Mediation Coordinator, ISBE Special Education Department.","https://schema.org",{"og:url":83,"og:type":124,"og:title":65,"og:site_name":95,"og:description":67},"article",{"robots":126,"canonical":83},"index,follow",{"doc_id":128,"site_id":62},534792,1791688969,{"code":4,"msg":5,"data":131},{"doc_id":128,"user_id":132,"nickname":92,"user_avatar":133,"doc_module":4,"category_id":34,"category_name":35,"doc_title":65,"doc_description":67,"doc_content":134,"file_id":135,"file_url":136,"file_type":137,"file_size":138,"view_count":52,"is_deleted":4,"is_public":8,"is_downloadable":8,"audit_status":8,"page_count":14,"language":139,"language_code":63,"site_id":62,"html_lang":63,"table_of_contents":140,"faqs":141,"seo_title":142,"seo_description":67,"update_tm":143,"read_time":24,"preview_page_count":4},137451207643,"https://ap-avatar.wpscdn.com/davatar_3d24733baf745e90a7e4bdd5f77d97b2","MEDIATION REQUEST FORM FOR SPECIAL EDUCATION DEPARTMENT  \n100 North First Street, N-253 Springfield, Illinois 62777-0001  \nSPECIAL EDUCATION DEPARTMENT  \nInstructions: 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.  \nPlease 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.  \nThis completed form should be submitted to:  \nMediation Coordinator  \nIllinois State Board of Education Special Education Department  \n100 North First Street, N-253 Springfield, IL 62777-0001  \nFax: (217) 782-0372  \nEmail: [statemediation@isbe.net](statemediation@isbe.net)  \nTelephone assistance: (217) 782-5589 or (866) 262-6663 TTY/TDD: (217) 782-1900  \n\n| SECTION I – STUDENT INFORMATION |  |  |\n| --- | --- | --- |\n| STUDENT FIRST NAME | STUDENT LAST NAME | DATE OF BIRTH (mm/dd/yyyy) |\n\nDISABILITY CATEGORY(IES) : (Check all that apply)  \nAutism  \nDeafness  \nDeafness-Blindness  \nDevelopmental Delay  \nEmotional Disability  \nHearing Impairment  \nIntellectual Disability  \nMultiple Disabilities  \nOrthopedic Impairment  \nOther Health Impairment  \nSpeech Language Impairment  \nSpecific Learning Disability  \nTraumatic Brain Injury  \nVisual Impairment  \nUnknown  \n\n| SECTION II – PARENT INFORMATION |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- |\n|  |  |  |  |  |  |  |  |  |\n| PARENT/GUARDIAN/SURROGATE PARENT NAME | DAY TELEPHONE (Include Area Code)  Home  Work |  |  |  |  |  |  | Cell |\n|  |  |  |  |  |  |  |  |  |\n| ADDRESS (Street, City, State, ZIP Code) |  | EMAIL |  |  |  |  |  |  |\n| NAME OF PARENT’S ATTORNEY/ADVOCATE (If applicable) | TELEPHONE (Include Area Code) |  |  |  |  |  |  |  |\n| ADDRESS (Street, City, State, ZIP Code) |  | EMAIL |  |  |  |  |  |  |\n\nISBE 34-15 (9/25) Page 1 of 2  \n\n| SECTION III – SCHOOL DISTRICT INFORMATION |  |\n| --- | --- |\n| DISTRICT NAME AND NUMBER | TELEPHONE (Include Area Code) |\n| ADDRESS (Street, City, State, ZIP Code) | EMAIL |\n| PRIMARY DISTRICT CONTACT NAME/TITLE | TELEPHONE (Include Area Code) |\n| ADDRESS (Street, City, State, ZIP Code) (If different from district) | EMAIL |\n| NAME OF DISTRICT ATTORNEY (If applicable) | TELEPHONE (Include Area Code) |\n| ADDRESS (Street, City, State, ZIP Code) | EMAIL |\n\nSECTION IV – DESCRIPTION OF THE ISSUE(S)  \nBrief description of the dispute and the resolution you are seeking:  \n(Do not go beyond space provided. Submit additional pages if necessary.)  \n\n| SECTION V – REQUESTOR INFORMATION |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n|  |  |  |  |  |  |  |  | DAY TELEPHONE (Include Area Code)  Home  Work |  |  |  |  |  |  |  |  |  |\n| NAME OF PERSON COMPLETING THIS FORM |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Cell |\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| EMAIL |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| IDENTIFY YOUR ROLE: |  |  |  |  |  |  | Parent’s Advocate |  | | Parent’s Attorney |  |  | District | | District’s Attorney |  |  |\n| | Parent/Guardian/Surrogate Parent | |  | Adult Student | |  |  |  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Have both parties agreed to state-sponsored mediation? |  |  |  |  |  |  |  Yes  No |  |  |  |  |  |  |  |  |  |  |\n| Date mediation request completed/submitted to the Illinois State Board of Education:   |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n\nISBE 34-15 (9/25)  \nPage 2 of 2  \nPrint  \nReset Form","cbCaiqOw42kI1dBg","https://ap.wps.com/l/cbCaiqOw42kI1dBg","pdf",335663,"English","# Section I – Student Information\n# Section II – Parent Information\n# Section III – School District Information\n# Section IV – Description of the Issue(s)\n# Section V – Requestor Information","[{\"question\":\"What is the purpose of this mediation request form?\",\"answer\":\"It initiates a request for state-sponsored mediation by collecting the information needed to start the process for special education disputes.\"},{\"question\":\"Who can submit a mediation request?\",\"answer\":\"Either the school district or the parent/guardian/surrogate parent/adult student may initiate the request.\"},{\"question\":\"How should the form be submitted to the Illinois State Board of Education?\",\"answer\":\"The completed form can be submitted via U.S. Mail, email, or fax to the Mediation Coordinator, ISBE Special Education Department.\"}]","MEDIATION REQUEST FORM FOR SPECIAL EDUCATION DEPARTMENT - ISBE 34-15 - Request for state-sponsored mediation | PDF",1791599066]