The New York State Education Department has published a revised Sample State Complaint Form which includes all elements required by IDEA and provides a document to submit a complaint to NYSED.  This form can be used when parents, individuals or organizations believe a school district or public agency has violated a requirement of Part B of IDEA or New York State laws or regulations related to students with disabilities.

http://www.vesid.nysed.gov/specialed/publications/policy/covercomplaint.htm