REQUEST FOR IMPARTIAL FAIR HEARING

I, 						am requesting an Impartial Fair Hearing because I am dissatisfied or disagree with a decision or delay concerning vocational rehabilitation services.
•	I have asked or plan to ask, the Client Assistance Program (CAP) to assist me: Yes No
•	I plan to use a representative other than CAP: Yes No	If Yes:
Name of Representative: 				                     						 
Address: 				                                     Phone#: 						 
City: 		        	                                     	   State: 	          Zip Code: 	           	
Write a brief statement of the issue(s) you would like resolved. (Attach additional pages, if needed.)

			
			
How could we resolve the issue(s) to your satisfaction?  (Attach additional pages, if needed.)

Signature:                                                                                                Date: 			
Address: 				                                                        Phone:                               	
City	                     				 		  State 		  Zip Code			   

Completed forms, questions or requests for this form in alternate format should be directed to: OVRS Dispute Resolution Coordinator, 500 Summer St NE, E-87, Salem, OR 97301-1120. Voice: 503-945-6253, Toll-Free: 1-877-277-0513. Toll-Free TTY: 1-866-801-0130 Fax: 503-947-5025. 

If you want outside help to resolve problems, the Oregon Client Assistance Program provides assistance to individuals who are receiving services or desire to receive services from OVRS.
They can be contacted at: Oregon Client Assistance Program, Oregon Advocacy Center, 620 SW 5th Ave, 5th Floor, Portland OR 97204-1428. Voice: 503-243-2081, Toll-Free: 1-800-452-1694. TTY: 503-323-9161, Toll-Free TTY: 1-800-556-5351. Fax: 503-243-1738. E-mail: welcome@oradvocacy.org

RESOLVING PROBLEMS
If at any point you are not satisfied with a decision, action or lack of action concerning your vocational rehabilitation services or program at the Office of Vocational Rehabilitation Services (OVRS), you have a right to a review of that decision or action.  Your counselor is available to assist you with any of the following:

Informal Negotiation and Problem-Solving:  We encourage you to discuss your dissatisfaction over the decision or action with your counselor and/or his or her supervisor first.  You can get help from the Client Assistance Program (CAP) or other advocate to do this. Other OVRS staff may become involved in finding a resolution of the problem(s).  

Formal Mediation:  
•	You may submit a written request for formal mediation to the Manager at the local OVRS Office or to the OVRS Dispute Resolution Coordinator, using the Request for Mediation form or its equivalent.
•	Formal mediation is a voluntary process. Both you and your OVRS counselor and/or staff person(s) directly involved in the dispute must be willing to participate before OVRS can schedule a formal mediation.  
•	In a formal mediation, the role of the professional, impartial mediator is to assist the mediation parties to effectively communicate with each other. The goal is for the parties themselves to work toward mutually acceptable solutions and to create a written, signed mediation agreement.
•	Before the formal mediation takes place, each participant must sign a document stating that all discussions that occur during the mediation process will be kept confidential by all participants and cannot be used as evidence in any subsequent impartial fair hearing or civil court proceeding.  
•	Your participation in a formal mediation does not affect your right to an impartial fair hearing.
•	To preserve your right to a hearing, you must submit your written request for mediation within 60 days of the action you dispute.
	
Impartial Fair Hearing:  
•	You may ask for an impartial fair hearing by submitting a written request to the OVRS Manager at the local OVRS office or to the OVRS Dispute Resolution Coordinator, using the Request for Impartial Fair Hearing form or its equivalent.  
•	You must file your written request within 60 days of the disputed action or decision, or within 60 days of the date of either a written notice that OVRS has declined formal mediation or a written notice that the formal mediation process has ended.
•	An impartial fair hearing is conducted by a trained impartial hearing officer. Both you or your advocate and a representative of OVRS have an opportunity to present your case, using witness testimony and other evidence regarding the issue(s) in dispute.
•	The impartial hearing officer will consider all the evidence and arguments. He or she will then make a decision based on the evidence and legal authority, including the Rehabilitation Act of 1973 as amended, federal regulations, Oregon State statutes and regulations governing OVRS, and OVRS policies that are consistent with federal and state legal requirements.