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Waiver/Waiting List State Hearing Request Form

DODD has created a State Hearing Request Form (DODD 11.18) for use to notify individuals of their rights to request a State hearing following an assessment using the Waiting List Assessment Tool. This form should be used in conjunction with a waiver/waiting list assessment conducted under OAC 5123-9-04 and should be mailed, emailed or handed to the individual at the same time as the assessment results. This form should also be used for those times an individual or the individual’s guardian, as applicable fails to respond to attempts by the County Board to establish contact to complete an assessment or declines an assessment of the individual using the waiting list assessment tool. Below is some guidance on filling out the form.

  • The County Board is required to fill out sections A and B of the form. Section C should be completed by the individual only if he/she is requesting a State hearing.
  •  The “mailing date” should identify the date the form was either mailed, emailed or delivered to the individual.
  •  The Bureau of State Hearings (BSH) will not process a hearing request made on behalf of an adult individual by a third party unless written proof of guardianship or representative authority is provided with the request. The questions on the form concerning parentage, guardianship and authorized representatives are to assist BSH in determining if a third party is a proper person to be representing the individual. Parents of a minor child do not have to provide written proof of their authority.
  •  Neither this form nor the written assessment results should be viewed as a substitute for personally making sure individuals, and/or their families, understand what actions have taken place, the reasons for those actions, and their rights to request a State hearing.
  •  If an individual wishes to request a State hearing, both pages of the request form should be submitted to BSH.