Revocation of Consent Form 102b

Background: Consent revocation applies to Consent Form 102b (Consent for Initial Provision of Special Education and Related Services or Section 504 and Related Services). A parent or legal guardian who initially consents to SPED or 504 services may choose to withdraw the consent. This revocation of consent must be made via the Revocation of Consent Form 102b. Once the DOE receives the written request, it is no longer obliged to provide SPED, Section 504, Related Services and FAPE to the student. If an IEP or 504 plan has not been developed, the DOE is not obligated to do a plan once consent has been revoked.

Obtaining this form happens in two parts:

1. Print form and send to parent – After receiving a verbal request to revoke consent, print the form via the eCSSS screen and send the form to the parent or legal guardian.

2. Record receipt of form in eCSSS – Once the school receives the signed form, record it in eCSSS.

Print Form

1. After receiving a verbal request to revoke consent, search for a student and select the appropriate Referral.

2. Locate Consent Form 102b:

1. • Expand DEFINE NEEDS.

   • Expand Eligibility Determination document under Eligibility Decision Date header.

   • Expand the PWN.

   • Highlight the Consent Form 102b.

3. From the Actions menu, select Print Revocation of Consent Form.

4. Print the form and provide to parent.

Record Receipt of Revocation

Upon receipt of the completed revocation form, enter the revocation information in eCSSS.

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

2. Locate Consent Form 102b:

   • Expand DEFINE NEEDS.

   • Expand Eligibility Determination document under Eligibility Decision Date header.

   • Expand the PWN. Locate and open Consent Form 102b.

3. Select the Consent Results tab and enter the following information in the Revocation Form Results box (field labels for 504 differ slightly):

   • Revocation Form Signed Date in MMDDYY format.

   • Name of Person Signing Revocation Form. Click Import Contact to select a Student Contact or type in a Contact Name.

   • School Received Revocation Form Date in MMDDYY format.

   • Consent Revocation Reason.

IDEA

504

5. When done, click Save.

On the Referral tab, the School Received Revocation Date will be displayed for Consent Form 102b under the header, Revocation Date.

For an overview, see Student Support Process - Quick Guide.