New Jersey Department of Health

Early Intervention System

P. O. Box 364

Trenton, NJ 08625-0364

AGREEMENT REACHED

WITHDRAW OF DISPUTE RESOLUTION REQUEST

Name of Individual/Organization Filing Complaint

Date

Participating Agency/Provider Complaint Filed Against

Nature of Complaint

Steps Agreed To

I have reviewed and discussed the above information with	.
I feel that adequate steps have been agreed upon that address my concern(s). Therefore, I am withdrawing my formal complaint at this time.

I understand that I may, at any time, re-file this complaint should the agreed upon steps not be carried out, if I am dissatisfied with the results or for any other reason. I also understand that I may file a complaint on other matters related to provision of early intervention services. I have received a copy of the “New Jersey Early Intervention System Family Rights.” These rights have been explained to me and I understand them.
Signature of Parent	Date

Agency/Provider agrees to implement/complete the steps contained in this agreement.

Signature of Procedural Safeguards Coordinator/Designee	Date

FHS-19

SEP 12

FHS-19, Agreement Reached-Withdraw of Dispute Resolution request

FHS-19, agreement reached, withdraw of dispute resolution request, early intervention system,

EWhite

2012-06-26

NJDOH