Special Education

Statement of Assurance - Out-of-State Residential Placement

Statement of Assurance - Out-of-State Residential Placement

New York State Approved Out-of-State Private Residential Program Placement Application2014-15 School Year - Word Word document (176 KB- includes instructions, application, assurance, referral chart and student profile)

Student Name:




I hereby certify the following:

  1. For an initial application to a NYS approved out-of-State private residential school, the CSE has provided a current individual evaluation or reevaluation of the student.  The individual evaluation and the classroom observation, where applicable, and any other evaluations necessary to describe the relevant circumstances leading up to the recommendation and the basis for the recommendation for change of placement have been completed within six months prior to the CSE’s initial recommendation for private school placement.
  2. The CSE has a current IEP for the student.
  3. The CSE has certified that the student is of school age and has a disability or combination of disabilities, and has further documented that the nature or severity of the student's disability is such that appropriate public facilities for instruction are not available.  The documentation reviewed by the CSE, establishing the nature and severity of the disability and warranting placement of the student in an approved private school, is maintained in the student’s education records and is available for review by NYSED.
  4. The following documentation submitted with this application is true and accurate.
    1. Documentation of efforts to place the student in a public facility and the outcomes of those efforts, and/or of CSE findings regarding the lack of suitability of each currently available and geographically accessible public placement;
    2. Documentation of all efforts to enable the student to benefit from instruction in less restrictive settings using support services and supplementary aids and special education services as set forth in subdivisions (d), (e), (f) and (h) of section 200.6 of the Regulations of the Commissioner of Education, and/or for those services not used, a statement of reasons why such services were not recommended;
    3. Detailed evidence of the student’s lack of progress in previous less restrictive programs and placements of a statement of reasons that such evidence is not available;
    4. Documentation that residential services are necessary to meet the student's educational needs as identified in the student's IEP, including a proposed plan and timetable for enabling the student to return to a less restrictive environment or a statement of reasons why such a plan is not currently appropriate;
    5. For initial placements, documentation that, upon determination that the student was first at risk of residential placement, the district sought parental (or student if age 18 or older) consent to invite county or State agency representatives to a CSE meeting to make recommendations concerning the appropriateness of residential placement and other programs and placement determinations;
    6. In the case of a recommendation by the CSE for placement of a student in an educational facility outside of the State, documentation that there are no appropriate public or private facilities for instruction available within this State; and
    7. In the case of a reapplication for State reimbursement of tuition costs, documentation of the continuing need for placement of the student in a private school.

Signature of School District Official:                         Date:                                                                                                                     

Last Updated: March 31, 2014