Office of Accountability

1.

Name of organization:

Primary location:

Contact information:
(phone / email / website):

LEAs where service will be provided:

2.

Years provider has delivered service:

3.

Evidence that services have been effective:

4.

Title of the instructional program, curriculum series to be used (if appropriate):

5.

Grade level(s) the provider will serve:

6.

Content area(s) provider will serve:

7.

Number of sessions provided per week, if applicable:

8.

Average length of each service session (minutes/hours):

9.

Duration of the available service period (e.g. September 1 – June 30; September 1 – August 31; weekends only; summer school only; specific number of weeks or hours, other, etc;):

10.

Type of instruction:

10a

Description of methods and strategies for serving eligible students with disabilities:

10b

Description of methods and strategies for serving eligible students with limited English proficiency:

11.

Qualifications of the service provider(s)/instructor(s):

12.

Reports to parents, teachers, and LEA (Content, frequency, method of delivery):

13.

Will transportation to the service location be provided at no charge if requested? (Note: LEAs are not required to provide or pay for transportation)

14.

Additional relevant information:

Other support services will be made avilable such as mental health counseling, parenting skills training, individual tutoring if needed as well as arts and crafts activities.