Create Revocation of Consent for Continued Services Form

When a student's parent/guardian submits a written statement revoking consent for continued services, record it in either the:

• Revocation of Consent for Continued Provision of SPED and Related Services screen.* For this task to be completed, the student must (a) have an Eligibility Determination with a Filed Date indicating IDEA eligibility and (b) an active IEP.
• Revocation of Consent for Continued Provision of 504 and Related Services screen.* For this task to be completed, the student must (a) have an Eligibility Determination with a Filed Date indicating 504 eligibility and (b) an active 504 Plan.  

This is different from Revocation of Consent Form 102b, which applies before a plan is developed. Revocation of continued services applies after a plan is developed.   

IMPORTANT NOTE: In addition to documenting when the school received this revocation of consent, the school must also issue a Prior Written Notice to the parent/guardian to bring this process to closure. Refer to the FAQs on the eCSSS homepage for a sample PWN related to revocation of consent for continued provision of SPED/related services.

* The DOE accepts any written method parents/guardians may use for the statement. However, if they prefer the official DOE form, you may provide it to them. Please inquire with eCSSS Help Desk about printing this form via eCSSS.

For IDEA: More background provided via this page in the eCSSS Knowledgebase (username/password required).

To complete a Revocation of Consent for Continued Services Form, do the following:

1. Search for a student and select the appropriate Referral.

2. Expand DEFINE NEEDS.

3. Highlight the appropriate Eligibility Determination document. From the Actions menu, select New Revocation of Consent for Continued Services. 

4. The Revocation of Consent for Continued Services Form is displayed.
   
   
   
   Do the following:

   1. In Written Revocation Signed Date field, enter the date the parent/guardian signed a written statement revoking consent of continued services.

   2. In School Received Signed Revocation Date field, enter the date the school received written revocation of consent from parent/guardian. Including a date in this field will “lock” the revocation document when saved, but you are able to edit a copy by clicking New Version (button displays after save).

   3. Enter the date for when Parent was Provided an Explanation and Copy of the Procedural Safeguards.

   4. For Name of Person Signing Written Revocation, click Import Contact. Use the drop-down menu to select the student contact who signed the revocation. If not on list, add the person as a parent/guardian on the Contacts tab.

5. Click Save. Once the form is saved, the student's eligibility status is automatically changed to Not Eligible on the Program tab.