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PD 3A/4 FORM CONTENTS:

transmittal letter

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Instructions and Definitions

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Section A

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Section B

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Section C

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Official Seal of the New York State Education Department THE STATE EDUCATION DEPARTMENT / THE UNIVERSITY OF THE STATE OF NEW YORK / ALBANY, NY 12234
_____________________________________________________________________________________________________
MANAGER, STRATEGIC EVALUATION DATA COLLECTION, ANALYSIS AND REPORTING
1613 ONE COMMERCE PLAZA
ALBANY, NEW YORK  12234
Tel. (518) 486-4678
Fax (518) 408-3363
 E-mail:  dataquest@mail.nysed.gov  

 

To:

 

 

Special Education Data Managers and
Chief Administrative Officers of:

Department of Correctional Services
Office of Children and Family Services
Office of Mental Health
Office of Mental Retardation and Developmental Disabilities

Date: September 2004
From: Inni Barone
Subject: PD-3A/4 – State Agency Report: Number of Students with Disabilities Provided Special Education on December 1, 2004 and the Settings in Which Students with Disabilities are Provided Education Services. Due between December 1, 2004 and December 17, 2004.

Attached is a PD-3A/4 form to be used to report your count of pre-school and school-age students with disabilities provided special education programs and services on December 1, 2004. This report also requests the settings in which students with disabilities are provided special education services. This report is due in the State Education Department between December 1, 2004 and December 17, 2004 and should be submitted to:

New York State Education Department
Office of Vocational and Educational Services for Individuals with Disabilities
Strategic Evaluation Data Collection, Analysis and Reporting
Room 1613, One Commerce Plaza
Albany, New York 12234

To be counted in this report, each student with a disability, on December 1, 2004, must meet the following criteria:

Federal law and regulation require that state agencies ensure an unduplicated count of students with disabilities. Before submitting the PD-3A/4 report, please complete local verification procedures to ensure that each student is counted only once. Such verification procedures may include visual scans, computer scans or other methods; and are especially important for agencies with multiple sites where students receive special education programs and services.

The New York State Education Department (SED) will confirm the accuracy of information included in this report as part of the program review process, or as is otherwise indicated. To facilitate such review for your agency, please maintain a list (hard copy or other readily retrievable format) of all students included in this child count until June 30, 2011. Upon completing local verification procedures, if it is determined that one or more counts are incorrect, a revised report (i.e., PD-3A/4 form) must be submitted to SED.

Compared to the PD-3A/4 report for 2003-2004, the PD-3A/4 report for 2004-2005 has been modified in the following ways:

Please note that the data collected through the PD forms are used in the following reports and activities:

If you have any questions or are in need of assistance in completing this report, please call the Strategic Evaluation Data Collection, Analysis and Reporting (SEDCAR) Unit by using the contact information provided in the letterhead. Thank you.

Attachment

cc: Rebecca H. Cort


The University of the State of New York
THE STATE EDUCATION DEPARTMENT
Office of Vocational and Educational Services for Individuals with Disabilities
Strategic Evaluation Data Collection, Analysis and Reporting
One Commerce Plaza – Room 1613
Albany, NY 12234-0001

PD-3A/4-State Agency Report: Number of Students with Disabilities Provided Special Education on December 1, 2004 and the Settings in Which Students with Disabilities are Provided Educational Services

Instructions:

  1. Return one copy of this report between December 1 and December 17, 2004 to the above address. (This report may not be signed or submitted prior to December 1, 2004.)

  1. Retain one copy (and supporting documentation) in your school for reference and audit purposes. The required retention period ends June 30, 2011.

  1. If you have questions about this report, please call (518) 486-4678 or e-mail your questions to dataquest@mail.nysed.gov

 

School Information

(Enter 12-digit SED Code Below)

                       
STATE AGENCY NAME

 

ADDRESS


 

CITY STATE ZIP

Contact Person Information*

NAME
TITLE
TELEPHONE FAX
E-MAIL ADDRESS

*All correspondence from the address at the top of this page will be directed to the contact person reported in the PD web-based system at http://pd.nysed.gov.  You may update the contact person at any time through the PD web-based system located at http://pd.nysed.gov.

Certification and Assurances

I have reviewed the information reported on this form and certify that this is a complete and accurate count of New York State students with disabilities served on December 1, 2004. I further certify that the students reported were served in accordance with their Individualized Education Programs and in accordance with State standards.

__________________________
Original Ink Signature

___________________
Date Signed

left arrow Chief Administrative Officer Must Sign and Date on or after December 1, 2004


__________________________________
Name of Chief Administrative Officer
(Please Type or Print)

     

 


Instructions and Definitions for Completing the PD-3A/4 Report

  1. Wherever information is requested regarding students' race/ethnicity, please use the following definitions to assist you in determining the most appropriate category for reporting students:
    American Indian/Alaskan Native: A person having origins in any of the original peoples of North and South America (including Central America) and who maintains tribal affiliation or community attachment.
    Asian or Pacific Islander: A person having origins in any of the original peoples of the Far East, Southeast Asia, the Indian subcontinent, or the Pacific Islands, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. The Pacific Islands include Hawaii, Guam, and Samoa.
    Black or African American (not Hispanic): A person having origins in any of the Black racial groups of Africa.
    Hispanic or Latino: A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.
    White (not Hispanic): A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

  2. Wherever students are to be reported by age, please report age as of December 1, 2004.

  3. If specific instructions for some tables are not provided below, they are included with each table of the PD-3A/4 form.

Directions and Definitions for Section C, Reports 1-14

Section C, Reports 1-14: There are two tables for each disability category- Table 1 and Table 2. These tables request placement information for all school-aged students with disabilities, ages 4-21, who are the responsibility of your CSE and are provided school-age special education programs and services on December 1, 2004.

Table 1: Report the number of students with disabilities who are educated in regular school buildings and removed from regular classes for "Less than 20%", "21% to 60%", or "More than 60%" of the school day or school week. "Regular school buildings" are buildings for both disabled and non-disabled school-age students. "Regular classes" are classes for both disabled and non-disabled school-age students. Time outside of regular classroom is a measure of the extent of removal from the regular classroom setting, NOT of the total amount of special education services provided. It is the percent of each school day or week that a student receives special education including related services, apart from non-disabled students while within a regular school building. For purposes of these data collection, students in the following settings should be reported in Table 1 (regular school buildings):

  • All State agency buildings that are attended by both disabled and non-disabled school-age students.

  • Students who attend regular school buildings for at least 50 percent of the school day or school week, even though they may attend programs in separate settings that include only students with disabilities for the rest of the day or week.

  • All age appropriate community-based settings that include individuals with and without disabilities, such as vocational sites, in which students with disabilities interact with non-disabled individuals other than non-disabled individuals who are providing services to the students.

  • In order to determine the percent of time students receive services outside regular classrooms (i.e., in rooms/groupings attended by students with disabilities only), it is important to consider where the service is provided rather than the type of service which is provided. To calculate the percentage of time outside the regular classroom, divide the number of hours the student receives special education and related services outside the regular classroom each day or week by the total number of hours in the school day or school week. Use the length of the entire school day, including all periods and lunch. The following examples are provided for purpose of clarification:

  • A student who attends a resource room for one period each day in which special education services are provided to a group of students with disabilities would be counted in Table 1, Line 1 since one period outside of regular classroom would constitute 20 percent or less of the school day.

  • A student who is assigned a full-time, one-to-one teacher aide, but who attends regular classrooms for 80 percent or more of the school day should be included in Line 1 of Table 1.

  • A student who receives special education services for two hours per day outside of regular classrooms would be reported on Table 1, Line 2. If the two hours of special education services are provided in the regular classroom, the student should be reported in Table 1, Line 1.

  • A student whose first period begins at 8:30 a.m. and last period ends at 2:30 p.m. would have a six-hour day or 30-hour week. If the student attended a special class for four 45-minute periods daily and participated in the general education environment for the remainder of the day, that student’s "time outside regular classroom" would be 15.0 hours per week or 50 percent of the week. Such a student would be reported in Table 1, Line 2.

  • Special education services provided outside the normal school day (e.g., before school or after school) should not be considered time outside the regular classroom, regardless of the type of services or where they are provided. Such students should be counted in Table 1, Line 1.

  • Students with disabilities who receive special education programs or services in regular classes that include non-disabled students should be reported in Table 1. This includes regular classrooms in which consultant teachers provide special education programs and services or regular classes in which special class programs are located.

  • Table 2: Report the number of students with disabilities who are educated in separate educational settings. These are settings that are attended by students with disabilities only. The definition of each separate educational setting follows:

    Special Public Day Schools- These schools include public school district or BOCES buildings that are attended by students with disabilities only. These schools also include Special Act School Districts if they are attended on a day school basis, and if they include students with disabilities only.
    Special Private Day Schools- Approved private schools for students with disabilities that are attended by students with disabilities only, on a day basis.
    Public Residential Facility- A public facility in which students reside and attend an education program affiliated with the agency, in buildings that serve only students with disabilities. If students with disabilities receive educational services in State agency buildings that are attended by both students with and without disabilities, they must be reported in Table 1.
    Private Residential Facility- A private facility in which students reside, and attend an education program operated by the agency, in buildings that serve only students with disabilities. If students with disabilities receive special education services in buildings that include disabled and non-disabled students, such students are to be reported in Table 1.
    Home- Use this setting if the State agency’s Committee on Special Education has determined that the most appropriate educational placement for the student is in the student’s residence (or "home"), and not in a school setting.
    Hospital or Other Non-School- These are settings in which students with disabilities are provided special education services based on their unique needs.


    State Agency Name:__________________________________  SED Code:____________
       
    Check here if no preschool students with disabilities are provided special education services by your agency on December 1, 2004. If so, skip Section A.
     
    Check here if no school-age students with disabilities are provided special education services by your agency on December 1, 2004. If so, skip Sections B and C.

    If both boxes are checked, your PD-3A/4 report is complete. Please complete page 1 and return the entire form to the address printed on the top of page 1.

    Section A: Preschool-Age Special Education Programs and Services

    Table 1: Number of preschool students with disabilities receiving special education programs and services in the State agency’s preschool special education program. Preschool students receiving evaluation services only are not to be counted.

     

    Ages 3-4*

    Age 2**

    If this agency operates an approved preschool special education program, report the count of students provided preschool special education programs and services on December 1, 2004.

       

    *Students who are 5 years of age are "school-age" students and must be reported in Sections B and C of this report and not in Section A.

    **Students who are 2 years old on December 1, 2004 (who will turn 3 years of age by December 31, 2004) and are receiving preschool special education services should be included in the column for students age 2.

    Section B: School-age Special Education Programs and Services

    Table 1: Provide an unduplicated count of all school-age students with disabilities provided special education, on December 1, 2004, by this agency.

    Line No.

    Report Each Student Only Once

    Age 4 to 21*

    1

    Count of school-age students with disabilities provided special education services in State agency's education programs or in programs in which students are placed by the State agency.

     

    *Only include 4 year old students if they are in your school-age program. Students are eligible to enroll in school-age (kindergarten) programs if they become five years old by December 1 or by a later date established by the school/agency. For example, if a student’s birthday is on December 5, 1999, and the school/agency policy for admission to school is "five years of age by December 31", the student could be enrolled in the kindergarten program and be 4 years old on December 1, 2004.

    Section B: Testing Accommodations

    Table 2: Of the school-age students reported in Section B-Table 1, Line 1, enter the number of students whose individualized education programs (IEPs) include one or more testing accommodations, by the appropriate age interval in Line 1. Students should be reported once, regardless of the number of testing accommodations listed in their IEPs. Also, all students should be reported regardless of whether they will be administered a State assessment during the 2004-2005 school year.

    Line No.

    Description

    Students Ages
    4 – 12

    Students Ages 13 – 15

    Students Ages 16 – 21

    1

    Total number of students provided any type(s) of testing accommodations.

     

    Section B: School-age Students with Disabilities who are also Students with Limited English Proficiency (Also referred to as English language learners.)

    Table 3: Of the school-age students with disabilities reported in Section B-Table 1, Line 1, report the subset of such students having limited English proficiency (LEP) in Line 1. Such students should be reported based on LEP designation, regardless of the extent or type(s) of LEP services provided.

    Line No. Description
    4-5 Years 6-11 Years 12-13 Years 14-17 Years 18-21 Years Total

    1

    School-age LEP Students with Disabilities

     

    Section B: Population and Poverty Counts

    Table 4: The numbers provided in this table will be used to determine a portion of this agency’s federal aid allocation under IDEA, under Sections 611 and 619.

    Line 1: Provide the total enrollment of all school-age students (disabled and non-disabled) who were provided educational services in kindergarten through grade 12 programs, on December 1, 2004. Do not include individuals who are of school-age but are not enrolled in a special and/or general education program.

    Line 2: Of the students reported in Line 1, provide the number of students who were eligible to receive a free or reduced price lunch.

     

    Section B: School-age Students with Disabilities by Age or Grade

    Table 5: For all students with disabilities reported in Section B, Table 1, Line 1, report the number of students by grade level in Part 1 below. For students with disabilities who are not enrolled in a grade, report them in Part 2 below by age. Each student with a disability is to be reported in only one Line of either Part 1 or Part 2. Assignment of students with disabilities should be reported by grade if students attend classes with a particular grade. If students with disabilities attend classes with more than one grade, report them in the grade that they attend for majority of their classes, or the grade with which they identify. Please note the total number of students with disabilities in Line 14 of Part 1 plus the total number of students with disabilities in Line 16 of Part 2 must equal the total number of students with disabilities reported in Section B, Table 1, Line 1.

    Part 1 - Number of Students with Disabilities in Each Grade-Regardless of Age

    Part 2 – Number of Students with Disabilities who are not Assigned to a Grade, by Age as of 12/01/04

    Line #

    Grade

    Number of Students with Disabilities

    Line #

    Age

    Number of Students with Disabilities

    1

    Kindergarten

     

    1

    Age 4

     

    2

    Grade 1

     

    2

    Age 5

     

    3

    Grade 2

     

    3

    Age 6

     

    4

    Grade 3

     

    4

    Age 7

     

    5

    Grade 4

     

    5

    Age 8

     

    6

    Grade 5

     

    6

    Age 9

     

    7

    Grade 6

     

    7

    Age 10

     

    8

    Grade 7

     

    8

    Age 11

     

    9

    Grade 8

     

    9

    Age 12

     

    10

    Grade 9

     

    10

    Age 13

     

    11

    Grade 10

     

    11

    Age 14

     

    12

    Grade 11

     

    12

    Age 15

     

    13

    Grade 12

     

    13

    Age 16

     

    14

    Total

     

    14

    Age 17

     
     

    15

    Ages 18-21

     
     

    16

    Total

     

     

    Section C: Educational Placement of School-age Students by Disability and Race/Ethnicity Information

    Directions: Please review directions and definitions for completing reports 1-14 beginning on page 2. The total number of students reported in reports 1-13 and in reports 15 and 16 must be equal to the total number of students reported in Section B, Table 1, Line 1.

    Report 1: Report of Students with Autism as of December 1, 2004

    Table1: In Regular School-Based Programs in buildings attended by disabled and non-disabled students (Consultant Teacher, Resource Room, Special Class, et. al.)

      A B C D E F
    Line Number Time OUTSIDE Regular Classroom

    Age Group

    4-5

    6-11

    12-13

    14-17

    18-21

    Total

    01

    20% or less

               

    02

    21% to 60%

               

    03

    More than 60%

               

    04

    Total

       

    Table 2: In Separate Settings outside of regular school facilities, in buildings that are attended by students with disabilities only. In Line 5, include students who are placed on home instruction by the CSE.

      A B C D E F
    Line Number Time OUTSIDE Regular Classroom

    Age Group

    4-5

    6-11

    12-13

    14-17

    18-21

    Total

    01

    Special Public Day School

               

    02

    Special Private Day School

               
    03 Public Residential Facility            
    04 Private Residential Facility            
    05 Home            
    06 Hospital or Other Non-school            

    07

    Total

       

    Report 2: Report of Students with Emotional Disturbance as of December 1, 2004

    Table 1: In Regular School-Based Programs in buildings attended by disabled and non-disabled students (Consultant Teacher, Resource Room, Special Class, et. al.)

      A B C D E F
    Line Number Time OUTSIDE Regular Classroom

    Age Group

    4-5

    6-11

    12-13

    14-17

    18-21

    Total

    01

    20% or less

               

    02

    21% to 60%

               
    03 More than 60%            

    07

    Total

       

    Table 2: In Separate Settings outside of regular school facilities, in buildings that are attended by students with disabilities only. In Line 5, include students who are placed on home instruction by the CSE.

      A B C D E F
    Line Number Time OUTSIDE Regular Classroom

    Age Group

    4-5

    6-11

    12-13

    14-17

    18-21

    Total

    01

    Special Public Day School

               

    02

    Special Private Day School

               
    03 Public Residential Facility            
    04 Private Residential Facility            
    05 Home            
    06 Hospital or Other Non-school            

    07

    Total

       

    Report 3: Report of Students with Learning Disabilities as of December 1, 2004

    Table 1: In Regular School-Based Programs in buildings attended by disabled and non-disabled students (Consultant Teacher, Resource Room, Special Class, et. al.)

      A B C D E F
    Line Number Time OUTSIDE Regular Classroom

    Age Group

    4-5

    6-11

    12-13

    14-17

    18-21

    Total

    01

    20% or less

               

    02

    21% to 60%

               
    03 More than 60%            

    07

    Total

       

    Table 2: In Separate Settings outside of regular school facilities, in buildings that are attended by students with disabilities only. In Line 5, include students who are placed on home instruction by the CSE.

      A B C D E F
    Line Number Time OUTSIDE Regular Classroom

    Age Group

    4-5

    6-11

    12-13

    14-17

    18-21

    Total

    01

    Special Public Day School

               

    02

    Special Private Day School

               
    03 Public Residential Facility            
    04 Private Residential Facility            
    05 Home            
    06 Hospital or Other Non-school            

    07

    Total

       

    Report 4: Report of Students with Mental Retardation as of December 1, 2004

    Table 1: In Regular School-Based Programs in buildings attended by disabled and non-disabled students (Consultant Teacher, Resource Room, Special Class, et. al.)

      A B C D E F
    Line Number Time OUTSIDE Regular Classroom

    Age Group

    4-5

    6-11

    12-13

    14-17

    18-21

    Total

    01

    20% or less

               

    02

    21% to 60%

               
    03 More than 60%            

    07

    Total

       

    Table 2: In Separate Settings outside of regular school facilities, in buildings that are attended by students with disabilities only. In Line 5, include students who are placed on home instruction by the CSE.

      A B C D E F
    Line Number Time OUTSIDE Regular Classroom

    Age Group

    4-5

    6-11

    12-13

    14-17

    18-21

    Total

    01

    Special Public Day School

               

    02

    Special Private Day School

               
    03 Public Residential Facility            
    04 Private Residential Facility            
    05 Home            
    06 Hospital or Other Non-school            

    07

    Total

       

    Report 5: Report of Students with Deafness as of December 1, 2004

    Table 1: In Regular School-Based Programs in buildings attended by disabled and non-disabled students (Consultant Teacher, Resource Room, Special Class, et. al.)

      A B C D E F
    Line Number Time OUTSIDE Regular Classroom

    Age Group

    4-5

    6-11

    12-13

    14-17

    18-21

    Total

    01

    20% or less

               

    02

    21% to 60%

               
    03 More than 60%            

    07

    Total

       

    Table 2: In Separate Settings outside of regular school facilities, in buildings that are attended by students with disabilities only. In Line 5, include students who are placed on home instruction by the CSE.

      A B C D E F
    Line Number Time OUTSIDE Regular Classroom

    Age Group

    4-5

    6-11

    12-13

    14-17

    18-21

    Total

    01

    Special Public Day School

               

    02

    Special Private Day School

               
    03 Public Residential Facility            
    04 Private Residential Facility            
    05 Home            
    06 Hospital or Other Non-school            

    07

    Total

       

    Report 6: Report of Students with Hearing Impairments as of December 1, 2004

    Table 1: In Regular School-Based Programs in buildings attended by disabled and non-disabled students (Consultant Teacher, Resource Room, Special Class, et. al.)

      A B C D E F
    Line Number Time OUTSIDE Regular Classroom

    Age Group

    4-5

    6-11

    12-13

    14-17

    18-21

    Total

    01

    20% or less

               

    02

    21% to 60%

               
    03 More than 60%            

    07

    Total

       

    Table 2: In Separate Settings outside of regular school facilities, in buildings that are attended by students with disabilities only. In Line 5, include students who are placed on home instruction by the CSE.

      A B C D E F
    Line Number Time OUTSIDE Regular Classroom

    Age Group

    4-5

    6-11

    12-13

    14-17

    18-21

    Total

    01

    Special Public Day School

               

    02

    Special Private Day School

               
    03 Public Residential Facility            
    04 Private Residential Facility            
    05 Home            
    06 Hospital or Other Non-school            

    07

    Total

       

    Report 7: Report of Students with Speech or Language Impairments as of December 1, 2004

    Table 1: In Regular School-Based Programs in buildings attended by disabled and non-disabled students (Consultant Teacher, Resource Room, Special Class, et. al.)

      A B C D E F
    Line Number Time OUTSIDE Regular Classroom

    Age Group

    4-5

    6-11

    12-13

    14-17

    18-21

    Total

    01

    20% or less

               

    02

    21% to 60%

               
    03 More than 60%            

    07

    Total

       

    Table 2: In Separate Settings outside of regular school facilities, in buildings that are attended by students with disabilities only. In Line 5, include students who are placed on home instruction by the CSE.

      A B C D E F
    Line Number Time OUTSIDE Regular Classroom

    Age Group

    4-5

    6-11

    12-13

    14-17

    18-21

    Total

    01

    Special Public Day School

               

    02

    Special Private Day School

               
    03 Public Residential Facility            
    04 Private Residential Facility            
    05 Home            
    06 Hospital or Other Non-school            

    07

    Total

       

    Report 8: Report of Students with Visual Impairments (including Blindness) as of December 1, 2004

    Table 1: In Regular School-Based Programs in buildings attended by disabled and non-disabled students (Consultant Teacher, Resource Room, Special Class, et. al.)

      A B C D E F
    Line Number Time OUTSIDE Regular Classroom

    Age Group

    4-5

    6-11

    12-13

    14-17

    18-21

    Total

    01

    20% or less

               

    02

    21% to 60%

               
    03 More than 60%            

    07

    Total

       

    Table 2: In Separate Settings outside of regular school facilities, in buildings that are attended by students with disabilities only. In Line 5, include students who are placed on home instruction by the CSE.

      A B C D E F
    Line Number Time OUTSIDE Regular Classroom

    Age Group

    4-5

    6-11

    12-13

    14-17

    18-21

    Total

    01

    Special Public Day School

               

    02

    Special Private Day School

               
    03 Public Residential Facility            
    04 Private Residential Facility            
    05 Home            
    06 Hospital or Other Non-school            

    07

    Total

       

    Report 9: Report of Students with Orthopedic Impairments as of December 1, 2004

    Table 1: In Regular School-Based Programs in buildings attended by disabled and non-disabled students (Consultant Teacher, Resource Room, Special Class, et. al.)

      A B C D E F
    Line Number Time OUTSIDE Regular Classroom

    Age Group

    4-5

    6-11

    12-13

    14-17

    18-21

    Total

    01

    20% or less

               

    02

    21% to 60%

               
    03 More than 60%            

    07

    Total

       

    Table 2: In Separate Settings outside of regular school facilities, in buildings that are attended by students with disabilities only. In Line 5, include students who are placed on home instruction by the CSE.

      A B C D E F
    Line Number Time OUTSIDE Regular Classroom

    Age Group

    4-5

    6-11

    12-13

    14-17

    18-21

    Total

    01

    Special Public Day School

               

    02

    Special Private Day School

               
    03 Public Residential Facility            
    04 Private Residential Facility            
    05 Home            
    06 Hospital or Other Non-school            

    07

    Total

       

    Report 10: Report of Students with Other Health Impairments as of December 1, 2004

    Table 1: In Regular School-Based Programs in buildings attended by disabled and non-disabled students (Consultant Teacher, Resource Room, Special Class, et. al.)

    A B C D E F
    Line Number Time OUTSIDE Regular Classroom

    Age Group

    4-5

    6-11

    12-13

    14-17

    18-21

    Total

    01

    20% or less

    02

    21% to 60%

    03 More than 60%

    07

    Total

     

    Table 2: In Separate Settings outside of regular school facilities, in buildings that are attended by students with disabilities only. In Line 5, include students who are placed on home instruction by the CSE.

      A B C D E F
    Line Number Time OUTSIDE Regular Classroom

    Age Group

    4-5

    6-11

    12-13

    14-17

    18-21

    Total

    01

    Special Public Day School

               

    02

    Special Private Day School

               
    03 Public Residential Facility            
    04 Private Residential Facility            
    05 Home            
    06 Hospital or Other Non-school            

    07

    Total

       

    Report 11: Report of Students with Multiple Disabilities as of December 1, 2004

    Table 1: In Regular School-Based Programs in buildings attended by disabled and non-disabled students (Consultant Teacher, Resource Room, Special Class, et. al.)

      A B C D E F
    Line Number Time OUTSIDE Regular Classroom

    Age Group

    4-5

    6-11

    12-13

    14-17

    18-21

    Total

    01

    20% or less

               

    02

    21% to 60%

               
    03 More than 60%            

    07

    Total

       

    Table 2: In Separate Settings outside of regular school facilities, in buildings that are attended by students with disabilities only. In Line 5, include students who are placed on home instruction by the CSE.

      A B C D E F
    Line Number Time OUTSIDE Regular Classroom

    Age Group

    4-5

    6-11

    12-13

    14-17

    18-21

    Total

    01

    Special Public Day School

               

    02

    Special Private Day School

               
    03 Public Residential Facility            
    04 Private Residential Facility            
    05 Home            
    06 Hospital or Other Non-school            

    07

    Total

       

    Report 12: Report of Students with Deaf - Blindness as of December 1, 2004

    Table 1: In Regular School-Based Programs in buildings attended by disabled and non-disabled students (Consultant Teacher, Resource Room, Special Class, et. al.)

      A B C D E F
    Line Number Time OUTSIDE Regular Classroom

    Age Group

    4-5

    6-11

    12-13

    14-17

    18-21

    Total

    01

    20% or less

               

    02

    21% to 60%

               
    03 More than 60%            

    07

    Total

       

    Table 2: In Separate Settings outside of regular school facilities, in buildings that are attended by students with disabilities only. In Line 5, include students who are placed on home instruction by the CSE.

      A B C D E F
    Line Number Time OUTSIDE Regular Classroom

    Age Group

    4-5

    6-11

    12-13

    14-17

    18-21

    Total

    01

    Special Public Day School

               

    02

    Special Private Day School

               
    03 Public Residential Facility            
    04 Private Residential Facility            
    05 Home            
    06 Hospital or Other Non-school            

    07

    Total

       

    Report 13: Report of Students with Traumatic Brain Injury as of December 1, 2004

    Table 1: In Regular School-Based Programs in buildings attended by disabled and non-disabled students (Consultant Teacher, Resource Room, Special Class, et. al.)

      A B C D E F
    Line Number Time OUTSIDE Regular Classroom

    Age Group

    4-5

    6-11

    12-13

    14-17

    18-21

    Total

    01

    20% or less

               

    02

    21% to 60%

               
    03 More than 60%            

    07

    Total

       

    Table 2: In Separate Settings outside of regular school facilities, in buildings that are attended by students with disabilities only. In Line 5, include students who are placed on home instruction by the CSE.

      A B C D E F
    Line Number Time OUTSIDE Regular Classroom

    Age Group

    4-5

    6-11

    12-13

    14-17

    18-21

    Total

    01

    Special Public Day School

               

    02

    Special Private Day School

               
    03 Public Residential Facility            
    04 Private Residential Facility            
    05 Home            
    06 Hospital or Other Non-school            

    07

    Total

       

    Report 14: Summary Report of All Students with Disabilities as of December 1, 2004

    The two sections below aggregate the data reported in Reports 1 to 13 to facilitate State and local data verification procedures. Completing these two tables will facilitate the reporting of race/ethnicity data in Reports 15 and 16.

    Table 1: In Regular School-Based Programs in buildings attended by disabled and non-disabled students (Consultant Teacher, Resource Room, Special Class, et. al.)

      A B C D E F
    Line Number Time OUTSIDE Regular Classroom

    Age Group

    4-5

    6-11

    12-13

    14-17

    18-21

    Total

    01

    20% or less

               

    02

    21% to 60%

               
    03 More than 60%            

    07

    Total

       

    Table 2: In Separate Settings outside of regular school facilities, in buildings that are attended by students with disabilities only. In Line 5, include students who are placed on home instruction by the CSE.

      A B C D E F
    Line Number Time OUTSIDE Regular Classroom

    Age Group

    4-5

    6-11

    12-13

    14-17

    18-21

    Total

    01

    Special Public Day School

               

    02

    Special Private Day School

               
    03 Public Residential Facility            
    04 Private Residential Facility            
    05 Home            
    06 Hospital or Other Non-school            

    07

    Total

       

    Notes for Reviewing Data Reported in Report 14 Above:

    • The Report 14 total in Table 1, Line 4, Column F, plus the total in Table 2, Line 7, Column F must equal the total in Section B, Table 1, Line 1 of this PD-3A/4 form.

    • The total in each cell of Tables 1 and 2 of Report 14 should be the cumulative total of the corresponding cells from Reports 1-13.

    • The totals on each line of Column F in Tables 1 and 2 above should be identical to the totals in Column F of each line in Tables 1 and 2 of Report 15.

    • The total for Table 1 plus Table 2 above should equal the total reported in Line 14 of Column F of Report 16.

    • The total for Report 14, Table 1, Columns D and E plus Table 2, Columns D and E must be equal to the total number of students reported in Report 17.

    Report 15: Report of All Students with Disabilities as of December 1, 2004, by Race/Ethnicity Category and Type of Placement

    For all students reported in Table 1 and Table 2 of Report 14, enter the number that appear to belong, identify with, or are regarded in the community as belonging to each race/ethnic group. (Each student should be counted once.) The Total (Column F) for each Line in this Report must match the Total (Column F) for each Line in Report 14.

    Table 1: In Regular School-Based Programs in buildings attended by disabled and non-disabled students (Consultant Teacher, Resource Room, Special Class, et. al.)

    Line
    Number

    Settings

    A B C D E F

    American Indian or Alaskan Native

    Asian or Pacific Islander

    Black
    (not of Hispanic origin)

    Hispanic

    White (not of Hispanic origin)

    Total

    01 20% or less            
    02 21% to 60%            
    03 More than 60%            

    04

    Total            

    Table 2: In Separate Settings outside of regular school facilities, in buildings that are attended by students with disabilities only. In Line 5, include students who are placed on home instruction by the CSE.

    Line
    Number

    Type of Setting

    A B C D E F

    American Indian or Alaskan Native

    Asian or Pacific Islander

    Black (not of Hispanic origin)


    Hispanic

    White (not of Hispanic origin)

    Total

    01 Special Public Day School            
    02 Special Private Day School            
    03 Public Residential Facility            
    04 Private Residential Facility            
    05 Home            
    06 Hospital or Other Non-School            
    07 Total            

    Report 16: Report of All Students with Disabilities as of December 1, 2004, by Race/Ethnicity Category and Type of Disability

    In the table below, report race/ethnicity data by disability for all students reported in Tables 1 and 2 of Reports 1 to 13.

    The total reported below in Column F for each disability must match the sum of totals reported in Tables 1 and 2 under the corresponding disability in Reports 1 to 13. Also, the total reported in each column below by race/ethnicity must be equal to the total reported in each column, by race/ethnicity in Table 1 plus Table 2 of Report 15.

    Racial/Ethnic Group

    Line Number

    Disability

    A B C D E F
    American Indian or Alaskan Native Asian or Pacific Islander Black 
    (not of Hispanic origin)
    Hispanic White 
    (not of Hispanic origin)
    Total
    01 Autism
    02 Emotional Disturbance
    03 Learning Disability
    04 Mental Retardation
    05 Deafness
    06 Hearing Impairment
    07 Speech or Language Impairment
    08 Visual Impairment (includes Blindness)
    09 Orthopedic Impairment
    10 Other Health Impairment
    11 Multiple Disabilities
    12 Deaf-Blindness
    13 Traumatic Brain Injury
    14 Total (Lines 1-13)

    Report 17: Report of Students with Disabilities who are 14 to 21 Years of Age as of December 1, 2004, by Race/Ethnicity Category. (These students are also reported in Reports 15 and 16 of this report.)

    In the table below, report race/ethnicity data for students with disabilities (ages 14-21) for whom the State agency has CSE Responsibility. The total number of students reported in Column F of this report must be the same as the total number of students reported in Report 14, Tables 1 and 2, Columns D plus E.

    Line
    Number

    Category of Students

    A B C D E F

    American Indian or Alaskan Native


    Asian or Pacific Islander

    Black (not of Hispanic origin)


    Hispanic

    White (not of Hispanic origin)

    Total

    01

    Students with Disabilities,
    Ages 14-21

               

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