Vocational and Educational Services for Individuals with Disabilities (VESID)
Special Education and Vocational Rehabilitation Services

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The Committee on Special Education (CSE)/Committee on Preschool Special Education (CPSE), with representation from the 4201 State-supported school, must complete this application and a STAC-1 form for a student to receive a Commissioner's Appointment.  It is essential that ALL REQUIRED SIGNATURES are obtained. 

Student Name ________________________________________________           DOB: ____/____/____ 

Type of Placement:        1       Initial Application: Initial placement/change in LEA/program change (e.g., Deaf Infant (DIP), Deaf Infant to Preschool or Preschool to School-Age or students who are attending a summer program only)

                                      1       Transfer: CSE/CPSE recommends an alternative 4201 State-supported school

LEA Name: __________________________________________________________________________

 Contact Person: ______________________________________________________________________ 

  Address:___________________________________________________________________________              Street                          City              Zip Code

 Phone Number: (_____)________________________ Fax Number (_____)____________________

Recommended 4201 School: ____________________________________________________________

 Phone Number: (_____)________________________ Fax Number (_____)____________________

Type of Program:         ____Deaf Infant / ____Preschool / ____School-Age 

____10-Month / ____12-Month / ____2-Month             ____Day / ____Residential

Date of PHC-10 Approval: ____/____/____                  Date of CSE/CPSE Meeting: ____/____/____

Parent/Guardian Name: _______________________________________________________________

  Address: ___________________________________________________________________________
Street                               City                   Zip Code
 Phone Number:  (______)__________________


Projected Date of Admission to 4201 School:  ____ /____ /___

                                 Statements of Assurance


All required CSE/CPSE members, the student's parent/guardian, the student when appropriate, and the representative from the State-supported school participated in the CSE/CPSE review and the CSE/CPSE determined that its recommendation for the student to receive his/her special education services at a 4201 State-supported school represents the least restrictive environment (LRE) for that student.  [8NYCRR 200.3(a)(1), 200.4(c)(3) 200.16 and 34CFR 300.344(a)(1),(2),(3) and (4)]

An individualized education program (IEP) has been developed and recommended by the CSE/CPSE. The IEP addresses all mandated areas including but not limited to  (1) a transition plan, when appropriate, and (2) a statement that confirms that the placement represents the Least Restrictive Environment (LRE) for this student since it was determined that there were no local public schools or BOCES programs that could provide the individualized education services required by this student.  [8NYCRR 200.4(c)(2), 200.4(d)(1), 34CFR 300.340, 300.342, 300.346 and 300.346(b)]



(1)           In developing the transition plan for transition services, defined in 8NYCRR 200.1(rr), the CSE/CPSE has addressed the following eight quality components: 

       The student is actively involved in transition planning and is supported in achieving desired adult goals.

     Family members and other community service agencies, as appropriate, are informed and involved in and committed to transition planning. 

        Transition planning addresses services and supports across all areas of the student's life. 

        A documented, sequential process for accessing transition services is developed. 

       Services and supports are provided in a timely manner as specified in the IEP, as agreed to by the student and family. 

        Unmet needs are identified and addressed. 

      Outcomes are measured in terms of the student's preparation for successfully achieving post-school living, learning and working goals. 

       A student from a linguistically and/or culturally diverse background receives these services in an instructional environment in accordance with his/her needs. 

(2)           The LRE statement addresses the reasons the student cannot be served in a general education setting; describes the supplemental services and personnel that were considered in an attempt to facilitate the student's placement in the general education setting; and lists the documentation reviewed which establishes the nature and severity of the disability warranting placement of the student in a 4201 State-supported school.


    Procedural due process relating to appropriate notices, timelines and safeguards has been adhered to in accordance with State and Federal regulations by the CSE/CPSE.  [8NYCRR 200.5 and 200.16 and 34CFR 300.500, 502-515, 562-569]

     The 4201 State-supported school will maintain a current IEP document that has been developed by the CSE/CPSE.  This document shall be implemented and maintained by the school in accordance with sections 8NYCRR 200.4(e), 200.5(a) and 200.5(a)(4).

The signatures below confirm that all required individuals were in attendance at the CSE/CPSE review and that the policies, procedures and State and Federal regulations previously listed in the Statements of Assurance pertaining to this student's special education placement have been adhered to by the Committee on Special Education/Committee on Preschool Special Education.

Signature of two Board-appointed CSE/CPSE representatives: 

____________________________________________                 _____________________
                              (CSE/CPSE Representative)                                                   (Date) 

____________________________________________                 _____________________                                                    (CSE/CPSE Representative)                                                  (Date) 

Signature of representative from the 4201 State-supported school:
*(If teleconferencing was utilized, please check box below and indicate name of person and title)  

____________________________________________                 ____________________
                                       Name/Title                                                                 (Date)

Signature of Parent/Guardian:
*(If teleconferencing was utilized, please check box below and indicate name of parent/guardian) 

_______________________________________                          _____________________
                                        Name                                                                       (Date)

 *Teleconferencing may be utilized, provided it occurred during the scheduled review. 


Important:  Please include STAC-1s with this application



New York State Education Department Use Only

Dear Parent/Guardian:

    Your child has been recommended and accepted for admission to the State-supported school indicated on this form.  An IEP to which you have agreed has been developed.  The New York State Education Department, Office for Special Education Services, has approved your child for appointment by the Commissioner of Education to be admitted to the school on the date indicated on the first page of this form.  Please contact your local school district and the State-supported school to arrange the transportation services for your child.  Should you have any questions, please contact our office at (518) 473-6108.

Signature of State Education Department Representative __________________________________

Date _______________________________

cc:        CSEo/ CPSEo/ REGIONo/ CBSTo 

4201 State-Supported School ______________________________________________________