Approved School-age Special Education Extended School Year July/August Special Class Programs - Program Modification Request Form
The University of the State of New York
THE STATE EDUCATION DEPARTMENT
P-12 Education: Office of Special Education
Albany, New York 12234
www.p12.nysed.gov/specialed/
The University of the State of New York
THE STATE EDUCATION DEPARTMENT
Rate Setting Unit
Albany, New York 12234
www.oms.nysed.gov/rsu
Approved School-age Special Education
Extended School Year July/August
Special Class Programs - Program Modification Request Form - Word 
(215 KB)
[To Request Modifications to Extended School Year July/August Special Classes Approved Prior to July/August 2013]
January 2013
Approved School-age Special Education Extended School Year July/August Special Class Program Modification Requests
- This program modification request is to be used by a school/agency which has already been approved by the New York State Education Department (NYSED) to operate extended school year (ESY) July/August full-day (9000) or half-day (9010) special classes under section 4408 of the Education Law.
- This program modification request must be completed and submitted no later than June 3, 2013 when a school proposes to take one or more of the following actions:
- Change the approved student/staff ratio
- Add an additional student/staff ratio to an existing program
- Modify the approved age range
- Add disability classifications
- Add related and other services
- Modify the hours or days of operation
- This program modification form has separate sections for 9000 full-day and 9010 half-day programs to allow a school/agency to modify existing NYSED-approved full-day and half-day programs with the submission of one request form.
Please note: A program modification request is not necessary when a school increases or decreases the number of special classes of the currently approved student/staff ratio for the ESY July/August programs for a school year.
General Instructions
- All applicants must complete Section A and Section D of the attached Program Modification Form and, as applicable, Section B and/or Section C.
- Program-related questions should be referred to NYSED's Special Education Quality Assurance Regional Office where the ESY July/August program is located (see page 3 for contact information).
- Fiscal questions should be referred to the Rate Setting Unit (see page 2).
- Submit the original completed modification request to the Office of Special Education by email (preferred method), facsimile or standard mail (see page 2 for contact information).
Contact Information
P-12: Office of Special Education
- Email: lkeech@mail.nysed.gov (preferred method of submission)
- Facsimile: (518) 473-5387 to the attention of Ms. Linda Keech
- Standard Mail:
NYS Education Department
P-12: Office of Special Education
89 Washington Avenue
Education Building, Room 309
Albany, NY 12234
Attention: 4408 Program Modification Review
- Telephone: (518) 473-6108
Rate Setting Unit
NYS Education Department
89 Washington Avenue
Education Building, Room 304
Albany, NY 12234
(518) 474-3227
(518) 486-3606 (FAX)
P-12: Office of Special Education
Special Education Quality Assurance (SEQA)
Jacqueline Bumbalo, Upstate Regional Coordinator
Belinda Johnson, NYC Regional Coordinator
Christopher Suriano, Upstate Regional Coordinator
Regional Offices
Western Regional Office
(NYS School for the Blind)
NYS Education Department
P-12: Office of Special Education
Special Education Quality Assurance
2A Richmond Avenue
Batavia, New York 14020
(585) 344-2002
Vacant, Supervisor
Eastern Regional Office
NYS Education Department
P-12: Office of Special Education
Special Education Quality Assurance
89 Washington Avenue
Room 309 – Education Building
Albany, New York 12234
(518) 486-6366
Diane Kallner, Supervisor
Central Regional Office
NYS Education Department
P-12: Office of Special Education
Special Education Quality Assurance
Hughes State Office Building
333 E. Washington St., Suite 527
Syracuse, NY 13202
(315) 428-4556
Suzanne Jackson, Supervisor
Long Island Regional Office
NYS Education Department
P-12: Office of Special Education
Special Education Quality Assurance
Perry B. Duryea, Jr. State Office Building,
Room #2A-5
250 Veterans Memorial Highway
Hauppauge, NY 11788
(631) 952-3352
Eileen Taylor, Supervisor
New York City Regional Office
NYS Education Department
P-12: Office of Special Education
Special Education Quality Assurance
55 Hanson Place,
Room 545
Brooklyn, NY 11217-1580
(718) 722-4544
Richard Governale, Supervisor
Kathy Cummings, Supervisor
Hudson Valley Regional Office
NYS Education Department
P-12: Office of Special Education
Special Education Quality Assurance
89 Washington Avenue
Room 309 – Education Building
Albany, New York 12234
(518) 473-1185
Sean Dwyer, Supervisor
Nondistrict Unit
NYS Education Department
P-12: Office of Special Education
Special Education Quality Assurance
Room 309 – Education Building
Albany, New York 12234
(518) 473-1185
Eileen Borden, Supervisor
Extended School Year July/August Special Class Program Modification Request
Section A: General Information
| 1.Legal Name of School/Agency | |
| 2.Mailing Address of School/Agency Administrative Office | Street |
| City State Zip | |
| 3.Address of Program Site(s), if different (attach addresses of other sites, if applicable) | Street |
| City State Zip | |
| 4.County and School District where Administrative Office is Headquartered | County |
| School District | |
| 5.Contact Person | 6.School's/Agency's 12-digit SED Code (required) |
| 7. Telephone/Email Address Area Code Number Ext. Email Address: |
8. Fax Number Area Code Number Ext. |
Section B: Full-day Special Class (9000)
Directions: Complete the chart below indicating the number of currently approved ESY July/August full-day (9000) special classes for each staffing ratio in Row 1, the proposed number of new classes in Row 2, and the new total numbers of classes the school/agency will operate in Row 3.
| Staffing Ratio | 15:1 | 12:1 1 | 12:1+1 | 6:1+1 | 8:1+1 | 12:1+(3:1) | Other |
| Current Number of Classes at Each Staffing Ratio | |||||||
| Requested Number of New Classes at Each Staffing Ratio | |||||||
| Total Number of Classes at Each Staffing Ratio (Current + New) |
| Current Program Model | Proposed Modifications |
| Age range of students: to | Age range of students: to |
| Check each disability the school/agency is currently approved to serve:
__ Autism __ Deafness __ Deaf-Blindness __ Emotional Disturbance __ Hearing Impairment __ Intellectual Disability __ Learning Disability __ Multiple Disabilities __ Orthopedic Impairment __ Other Health Impairment __ Speech or Language Impairment __ Traumatic Brain Injury __ Visual Impairment (including Blindness) | Check each disability the school/agency proposes to add to its existing program model: __ Autism __ Deafness __ Deaf-Blindness __ Emotional Disturbance __ Hearing Impairment __ Intellectual Disability __ Learning Disability __ Multiple Disabilities __ Orthopedic Impairment __ Other Health Impairment __ Speech or Language Impairment __ Traumatic Brain Injury __ Visual Impairment (including Blindness) |
| Check each related/other service currently approved by NYSED for this program: __ Audiology Services __ Counseling __ Occupational Therapy __ Physical Therapy __ Psychological Services __ School Social Work __ Speech/Lang. Therapy __ Vision Services __ Other: __ Other: __ Other: __ Other: |
Check each related service the school/agency proposes to add to the existing program:
__ Audiology Services __ Counseling __ Occupational Therapy __ Physical Therapy __ Psychological Services __ School Social Work __ Speech/Lang. Therapy __ Vision Services __ Other: __ Other: __ Other: __ Other: |
| Number of hours of daily instruction excluding the lunch period and transportation: | Proposed number of hours of daily instruction excluding the lunch period and transportation: |
Section C: Half-day Special Class (9010)
Directions: Complete the chart below indicating the number of currently approved ESY July/August half-day (9010) special classes for each staffing ratio in Row 1, the proposed number of classes in Row 2, and the new total numbers of classes of each staffing ratio the school/agency will operate in Row 3.
| Staffing Ratio | 15:1 | 12:1 2 | 12:1+1 | 6:1+1 | 8:1+1 | 12:1+(3:1) | Other: |
| Current Number of Classes at Each Staffing Ratio | |||||||
| Requested Number of New Classes at Each Staffing Ratio | |||||||
| Total Number of Classes at Each Staffing Ratio (Current + New) |
| Current Program Model | Proposed Modifications |
| Age range of students: to | Age range of students: to |
| Check each disability the school/agency is currently approved to serve: __ Autism __ Deafness __ Deaf-Blindness __ Emotional Disturbance __ Hearing Impairment __ Intellectual Disability __ Learning Disability __ Multiple Disabilities __ Orthopedic Impairment __ Other Health Impairment __ Speech or Language Impairment __ Traumatic Brain Injury __ Visual Impairment (including Blindness) |
Check each disability the school/agency proposes to add to its existing program model: __ Autism __ Deafness __ Deaf-Blindness __ Emotional Disturbance __ Hearing Impairment __ Intellectual Disability __ Learning Disability __ Multiple Disabilities __ Orthopedic Impairment __ Other Health Impairment __ Speech or Language Impairment __ Traumatic Brain Injury __ Visual Impairment (including Blindness) |
| Check each related/other service currently approved by NYSED for this program: __ Audiology Services __ Counseling __ Occupational Therapy __ Physical Therapy __ Psychological Services __ School Social Work __ Speech/Lang. Therapy __ Vision Services __ Other: __ Other: __ Other: __ Other: |
Check each related service the school/agency proposes to add to the existing program: __ Audiology Services __ Counseling __ Occupational Therapy __ Physical Therapy __ Psychological Services __ School Social Work __ Speech/Lang. Therapy __ Vision Services __ Other: __ Other: __ Other: __ Other: |
| Number of hours of daily instruction excluding the lunch period and transportation: | Proposed number of hours of daily instruction excluding the lunch period and transportation: |
Section D: Program Description
Please provide a description of the reason(s) for the program modification(s) [use additional sheets if necessary]:
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