The University of the State of New York THE STATE EDUCATION DEPARTMENT Office of Vocational and Educational Services for Individuals with Disabilities Albany, NY 12234 www.p12.nysed.gov   (518) 473-6108

The University of the State of New York THE STATE EDUCATION DEPARTMENT Rate Setting Unit Albany, NY 12234 www.oms.nysed.gov/rsu     (518) 474-3227

 

 

PROGRAM INFORMATION RECORD FORM

Application for Private School-Age (5-21) Special Education Programs - Word (157 KB) or PDF (199KB)

In-State or Out-of -State
Day/Residential 

 

 

Pursuant to Article 89

(Chapter 853 of the Laws of 1976)

Of the New York State Education Law

 

 

JULY 2005

Application for School-Age Special Education Program for both In-State or Out-of-State Programs 

Article 89 of the New York State Education Law provides that students with disabilities may be educated in approved private schools at public expense if it has been determined that school districts do not have appropriate programs to meet the needs of these students.  "The Program Information Record Form" is a 16-page program application to be used by private agencies applying for the first time to receive public funding to operate a school-age day/residential program for students with disabilities.

 

THIS APPLICATION IS DIVIDED INTO THE FOLLOWING SECTIONS:

Section 1:   Agency/School Program Identifying Information

Section 2:   Licenses/Charters/Certifications         

Section 3: Population to be Served         

Section 4: Special Education Class-Size Matrix

Section 5:  Curriculum Program Description         

Section 6:  Staffing Matrix         

Section 7:  Procedural Safeguard Compliance         

Section 8: Statement of Assurances         

Section 9: Fiscal Information         

         

GENERAL INSTRUCTIONS:

• All applicants must complete all sections. 

• All in-state applicants must provide documentation of need such as a list of students who cannot be served in the public schools or in programs at their local Board of Cooperative Educational Services (BOCES) programs or at already approved Article 89/Chapter 853 private school programs. This required documentation should include letters of support from local school districts and/or BOCES that document the need for the private special education program. Please refer to the November 1996 memorandum from Lawrence C. Gloeckler entitled "Procedures for Program Application and Expansion of In-state Private Schools and Center-based Preschool Programs for Students with Disabilities” at: http://www.p12.nysed.gov/specialed/publications/qa/programexpansion.pdf

Applications for in-state schools that do not provide documentation of regional need, including letters of support will not be considered for approval.

• The Department will determine the need to approve out-of-state schools based on the unavailability of sufficient and appropriate in-state placements and the uniqueness of the special education program to be offered to New York State students. 

• All applicants must submit written responses to all applicable items in the narrative sections of this application. 

• All applicants must sign and date the Statement of Assurances at the end of page 15.

• All applicants must submit site accessibility documentation from a licensed professional architect or engineer that the program meets the accessibility requirements of the Americans with Disabilities Act (ADA). All school-age programs seeking program approval must provide special education programs consistent with accessibility requirements of the ADA to ensure that the continuum of services options for all school-age special education programs are accessible to students, parents, staff and visitors. 

• All applicants must provide an assurance that parents of New York State students attending the school, governed by Article 89 of the NYS Education Law, will not be asked to make any payments for any allowable costs for students placed according to New York State regulations. [200.7(b)]

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RESOURCES TO ASSIST APPLICANTS

• Program related questions should be referred to staff in the appropriate Regional Office for Special Education Quality Assurance: http://www.p12.nysed.gov/specialed/quality/qaoffices.htm or the Central Office Administrative Support Services Team at (518) 473-6108. 

• The Office of Vocational and Educational Services for Individuals with Disabilities (VESID) website (http://www.p12.nysed.gov) contains information regarding such topics as policy, funding, frequently asked questions, publications, transition, data and research. 

• Parts 200 and 201 of the Regulations of the Commissioner of Education are available at: http://www.p12.nysed.gov/specialed/publications/lawsregs/part200.htm.  

• Part 100 of the Regulations of the Commissioner of Education is available at: http://www.p12.nysed.gov/part100/opener.html.  

• The New York State Education Department Learning Standards are available at: http://vls.nysed.gov/vls/.  

• The Learning Standards and Alternate Performance Indicators for students with disabilities are available on the EMSC website at:  http://www.p12.nysed.gov/specialed/publications/learnstand/lrnstdi.htm.  

• Additional resources are available on the State Education Department website (www.nysed.gov), including the Office of Professions (www.op.nysed.gov) and the Office of Teaching Initiatives (www.highered.nysed.gov/tcert/).

• Fiscal questions regarding tuition rate setting procedures for approved private schools should be referred to staff of the Rate Setting Unit at (518) 474-3227.  Additional rate setting information is also available on their website (http://www.oms.nysed.gov/rsu/). 

• List of additional resources or other helpful websites:

http://www.p12.nysed.gov/specialed/publications/home.html

      http://www.p12.nysed.gov/specialed/resources.htm

 

• Family Educational Rights and Privacy Act (FERPA) – A Federal Law that protects the privacy of student education records (34 CFR Part 99)  http://www.ed.gov/policy/gen/guid/fpco/ferpa/index.html

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Applicants must submit the following (please label items):

 

Required attachments by Application Section:	In-State		Out of State
	Day	Residential	Day	Residential
1.   Documentation of Need/ Letters of Support
2.  Copy of Educational Program License or Charter
3.   Copy of Residential License(s)
4.   Secondary School Registration (if appropriate)
5.   Organizational Chart listing Titles of Proposed  Staff Members
6.   Copy of Certificate of Incorporation with purpose section and filing document, and any related consents
7.   Policy on admission and discharge procedures regarding students with disabilities
8.   Copy of Certificate of Occupancy
9.   Most recent Fire Inspection Report
10.   Fire/Disaster Plan
11.   Evacuation Plan for Nonambulatory Children
12.   School Calendar for school year and    July/August, if applicable.
13.   Copy of Building Lease (if building is rented or leased)
14.   Copy of Amortization Schedule (if building is owned or less than arm’s length lease)
15.   Copy of Floor Plan (for all program sites)
16.   Typed Narratives  (see pages 10, 12, 13)
17.    Copies of Certification(s) for professional staff, including bilingual or ESL staff          (applies to active, operating school programs)
18.   Documentation from an architect or engineer of accessibility consistent with the Americans with Disabilities Act (ADA)
19.   Health/ Safety Policies
20.   Assurances on Page 15 have been signed

 

Applications will be considered incomplete if the ABOVE LISTED required attachments are not included. Incomplete applications will not be considered for approval.

 

A written notification of approval by the State Education Department will only be granted after the application is found to be complete and consistent with applicable laws and regulations. Applicants that are denied approval will be given a written explanation of the reason(s) for denial.

 

Please submit one (1) original and two (2) copies of the application to:

 

General Information

*This information is required and will be used for Department electronic mailings.

 Private Entity:          

a) Corporation (Specify Type) ______________________________________________           Date of Incorporation _____________

b) Partnership (Specify Type) _______________________________________________           Date of Formation _______________

c) Other (Specify Type) ___________________________________________________          Date of Formation _________________

 

15.     For-Profit or Nonprofit:  (for in-state applicants only) Check only one.

a) For-Profit (Business Corporation Law) Attach a copy of the certificate of incorporation with purpose section or registration pursuant to NY Business Corporation Law (and any certificates of amendment), along with the related consent(s) of the Commissioner of Education.

b) Nonprofit (Education Corporation or Not-for-Profit Corporation)

Education Corporation

Attach a copy of the charter from the Board of Regents (and any charter amendments)

Not-for-Profit Corporation

Attach a copy of the certificate of incorporation with purpose section pursuant to NY Not-for-Profit Corporation Law (and any certificates of amendment), along with the related consent(s) of the Commissioner of Education.

 

16. Licenses/Charters/ Certifications (for out-of-state applicants)

 

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Population to be Served

 

On Line 1, enter the student capacity for both the school year and summer extended school year sessions.

 

On Line 2, enter the age range of the students in the program.

 

On Line 3, enter the grade levels of the students in the program.

 

Student Enrollment Data	School Year	Summer
1.   Student Capacity of Program
Please check a box for each disability category to be   served.
Autism
Emotional Disturbance
Learning Disability
Mental Retardation
Hearing Impairment
Deafness
Speech Impairment
Visual Impairment
Orthopedic Impairment
Other Health Impairment
Multiple Disabilities (List components below*)
Deafness/Blindness
Traumatic Brain Injury
2.   Age Range of Students in the Program
3.   Grade Levels of Students in the Program

* List Components of Multiple Disabilities:

_____________________________________________________________________________

_____________________________________________________________________________

Identify unique components of the educational/residential programs such as specialized interventions for students with concomitant disorders (e.g., students with Asperger’s Syndrome, Tourette’s Syndrome, Prader Wili or other eating disorders, or who may be medically fragile).

Please complete the chart below.

If there are more than five (5) classes in the program, please make copies and attach to the application.

	Class 1	Class 2	Class 3	Class 4	Class 5
Maximum Class Size
Age Range of Students
Instructional Levels
Number of Teachers
Number of Certified Teaching Assistants
Number of Teacher Aides
Other Professionals Assigned to Each Class (List Separately)

 

List below the related services (e.g., speech and language therapy, occupational therapy, physical therapy) that are available to the students in this program.

________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________   

Describe services available to be provided to students who are English Language Learners/Limited English Proficiency (ELL/LEP).

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Curriculum Program Description

Provide a BRIEF [not to exceed three (3) pages] typed narrative in answer to each of the following:

• Describe how the school’s education program will address the New York State Learning Standards. The NYS Learning Standards in the seven (7) curriculum areas can be accessed at: http://vls.nysed.gov/vsl/.  

• Describe how instruction will be provided consistent with Part 100 requirements and New York State Learning Standards:
  • at the elementary level (if applicable)
  • at the middle level (if applicable)
  • at the secondary level (if applicable)

Accountability

Provide a BRIEF typed narrative in answer to the following:

• Describe how the students in the education program will have access to New York State assessments, including the New York State Alternate Assessment (NYSAA), Regents Competency Tests (RCT) and Regents examinations and New York State English As a Second Language Achievement Test (NYSESLAT) if applicable.

Other Requested Information

• Attach a copy of the program’s policy on admission and discharge procedures regarding students with disabilities. Include a brief description of the criteria and procedures to be followed when a student may be ready for a least restrictive environment.

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List each member of the professional, supervisory or administrative staff, related services staff, educational
services staff (teachers, teaching assistants, teacher aides), medical staff; their certification or licensure, and their allocation of time for the school-age special education program(s) proposed. In addition, include the time that these staff members spend in the provision of these services in other programs operated by this agency. Please refer to Appendix R-Section 51.0 of the New York State Consolidated Fiscal Reporting and Claiming Manual at this website for information concerning the Position Titles and Codes:  
http://www.oms.nysed.gov/rsu/Manuals_&_Forms/Manuals/CFR/200405/04-05cfrapp.pdf      

Position	Program Titles and Codes	Type of Certification or License Held	Certificate/ License Number	Specify if position is: Employed (E) or Contracted (C)	Hours Per Week for Special Class Program	Hours Per Week for Related Services	Hours Per Week for Other Programs	Total Work Hours Per Week

 

• Provide the plan for staff supervision, including employed and contracted staff.
• Indicate the name and title of any individual who will have direct supervisory responsibilities for the education program.  Provide the supervisor’s qualifications to document an appropriate level of experience.  (If an administrator or supervisor is serving more than 25 percent of his or her assignment in such capacity, a New York State certificate valid for administrative and supervisory service is necessary and should be indicated on the administrator’s or supervisor’s qualifications.  For out-of-state schools, a state certification for administrative service is necessary.
• Include, in addition to the staffing matrix, a list of all of the primary duties and responsibilities of the administrative staff members listed (for example, 75 percent FTE secondary special education teacher, 25 percent FTE secondary program supervisor).
• Provide a plan for staff in-service training and any other professional development activities to ensure that personnel are appropriately and adequately prepared, trained, and have the content knowledge and skills to meet the needs of the students with disabilities served by this program.

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Provide a BRIEF typed narrative in answer to each of the following:

• Procedural Safeguards for students with disabilities subject to discipline:
   
  • Provide a copy the conduct and discipline policies in accordance with Part 201 of the Commissioner’s Regulations.
  • Parts 200 & 201 of the Commissioner’s Regulations are available at this site: http://www.p12.nysed.gov/specialed/publications/lawsandregs/coverpage.htm

Submit policies and procedures that address the following health and safety concerns:

• serious health emergencies (include the distance to nearest hospital)
• medication administration
• procedures and in-service training provided to staff to ensure that any unusual medical and health needs of the students will be met in an appropriate manner
• use of psychotropic medication
• incident procedures
• abuse prevention procedures (physical/sexual)

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ASSURANCES FOR SCHOOL-AGE SPECIAL EDUCATION PROGRAMS

Special education programs shall be provided in accordance with Article 89 of the Education Law and Parts 200, 201 and 100 (where applicable) of the Regulations of the Commissioner of Education.

THE AGENCY DIRECTOR OF THE SCHOOL MUST INITIAL EACH ONE OF THE ASSURANCES LISTED BELOW. 

____The special education program and all professional instructional and supervisory staff shall meet all certification and education standards pursuant to Part 200 and Part 80 of the New York State Regulations of the Commissioner of Education or pursuant to the state in which the program is located.

_____Residential school applicants:  The backgrounds of all applicants for employment or voluntary work are reviewed, evaluated and verified pursuant to Section 200.15 (b)(6) of the NYS Regulations of the Commissioner of Education.

_____Procedural safeguards for the discipline of students with disabilities are consistent with Part 201 of the NYS Regulations of the Commissioner of Education.

_____Students have access to the general curriculum consistent with the NYS learning standards. [8 NYCRR Section 100.1(t)] 

_____Only school-age students with disabilities who require a separate facility are   served by the school. [8 NYCRR Section 200.7(a)(2)(i)(a)]

_____The special education program shall be in operation for not less than 180 instructional days each year and 30 days if the program has an extended school year program. The program will operate for not less than five hours of instruction for students whose chronological ages are equivalent to those of students in grades K through 6, and not less than 5 ½ of instruction for students whose chronological ages are equivalent to those of students in grades 7 through 12. [8 NYCRR Section 200.7(b)(5), Section 200.1 (q)]

_____Special education and related services, including class sizes/staffing ratios, shall be provided consistent with each student’s Individualized Education Program (IEP). [8 NYCRR Section 200.6(a)(2)]

_____The program shall provide the Committee on Special Education (CSE) of the appropriate school district with a written report of each student’s program upon request and at least annually. [8 NYCRR Section 200.7(c)(4)]

 _____ Any significant medical or other emergency will be reported immediately to the parents, home school district CSE and to the NYS Office of Vocational and Educational Services for Individuals with Disabilities (VESID). This address is:  NYS EMSC, Statewide SEQA Coordinator, Room 1624-One Commerce Plaza, 99 Washington Avenue, Albany, NY 12234.

_____ For school district placements, no student will be admitted without a current and appropriate IEP from the CSE of the school district where the student resides. [8 NYCRR Section 200.6(i)(1) & (2)]

 _____ Parents of students attending a school governed by Article 89 shall not be asked   to make any payments for allowable costs for students placed according to New York State regulations. [8 NYCRR Section 200.7(b)]

_____A copy of the school’s policy on the use of psychotropic medication will be provided to the student’s parents if the school uses this type of medication. [8 NYCRR Section 200.5(a)(5)(vii)]

 _____The chief executive officer of each new in-state school program located within a public school district shall provide to the superintendent of schools information about the school’s safety plan including school population, number of staff, transportation needs and the business and home telephone numbers of key officials. [8 NYCRR Section 155.17(k)] (Except for New York City)

_____ The agency shall not close, transfer its ownership or voluntarily terminate any of its approved special education programs until notice has been received and approved by the New York State Education Department. The Department must receive such notice at least 90 days before the intended effective date. Services to students with disabilities shall not cease to be provided until a transfer of such students has been arranged. [8 NYCRR Section 200.7(e)]

______Appropriate accounting documentation will be maintained, and necessary financial reports will be provided to the New York State Education Department. [8 NYCRR Section 200.9(d) & (e)]

_____ At least 12 fire drills will be conducted during the school year, eight of which must be held between 9/1 and 12/1 of each school year. A fire drill log specifying time conducted, evacuation time, and any difficulties encountered during the fire drill will be maintained. [Section 807 of the Education Law]. For programs operating on a 12-month basis, two additional fire drills are required to be conducted during the months of July and August. [Section 807 of the Education Law]

     ______ The agency will comply with all applicable fire and safety regulations of the State and municipality in which the program is located, including an annual fire safety inspection. [8 NYCRR Section 200.7(a)(2)(i)(c)]

_____ Changes to program approvals will not be implemented without prior approval by the New York State Education Department.

 

I, the undersigned, assure that all of these requirements will be met.

Name (Agency Director)

Signature _____________________________________ Date