CASE STUDY COMMITTEE WRITTEN NOTICE
REFUSAL OF PARENTAL REQUEST
Privacy Act Notice: Authority to Collect Information: 20 U.S.C. 927(c) and 10 U.S.C. 2164(f), as amended; E.O 9387; the Privacy Act of 1974,
as amended, 5 U.S.C. 552a. Principal Purpose: The information will be used within the DoD to determine the services to be provided to a
student to assist the child to receive a free appropriate public education. Disclosure to the Agency of the information requested on this form is
voluntary; but failure to provide all requested information may result in the delay or denial of student services. DoDEA may disclose information
requested in this form to other DoD activities and contracted service providers who require the information to deliver educational services to the
child and for valid medical, law enforcement or security purposes, or for use in litigation concerning the delivery of student. Routine Uses:
Disclosure of information contained in this form is authorized outside the DoD in accordance with the “Blanket Routine Uses” described at the
beginning of the Office of the Secretary of Defense’s compilation of systems of records notices, published at
http://www.defenselink.mil./privacy/notice/osd.
To: _____________________________________________
Date:___________________
(Name of Sponsor, Guardian, or Student 18 and over)
Re: _____________________________________________
(Name of Student)
The purpose of this notice is to inform you that the Case Study Committee reviewed your request
dated ______________ which would have initiated or changed your child’s identification, evaluation,
education placement, or provision of FAPE. Based on the CSC’s review, the school has decided not to
act on your request. The CSC’s reasons for refusing your request are described below.
Description of the action refused by the school:
______________________________________________________________________________
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