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 - WordWord Document (157 KB) or PDF PDF Document (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:

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

 ^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^

RESOURCES TO ASSIST APPLICANTS

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

 

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 armís 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:

 

New York State Education Department

Vocational and Educational Services for Individuals with Disabilities (VESID)

Central Office Administrative Regional Support Services Team

One Commerce Plaza, Room 1624

Albany, NY 12234

Attention: School-Age Application



General Information

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

14. Entity Type: Check only one

 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)

Provide the name and telephone number of the state education department contact person in the state in which the education program is located. 

Name:____________________________ Telephone Number:
____________________

Provide the name of the state agency (ies) and contact person(s) with telephone number for the residential components.    

State Agency (ies) _______________________________________________ 

 Name:__________________________ Telephone Number: _______________ 

Attach documentation of education program approval including the most recent monitoring report performed by the state education department where the education program is located.

Does the state authorize school district placements in the school and residence of your agency? o  Yes        o  No
Attach documentation of residential license or certification. 
Attach documentation of secondary school registration, if appropriate.

 

 

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 Aspergerís Syndrome, Touretteís 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).

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________


Curriculum Program Description

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

Accountability

Provide a BRIEF typed narrative in answer to the following:

Other Requested Information


STAFFING  (Duplicate this page as necessary.)
 

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

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


 

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 Ĺ 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 studentís 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 studentís 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 schoolís policy on the use of psychotropic medication will be provided to the studentís 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 schoolís 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



Fiscal Information for School-Age Special Education Programs

Agencies/private schools applying for approval are not required to submit a budget.

Tuition Reimbursement Methodology [8 NYCRR 200.9(2)(viii)]

     The tuition rate for these programs seeking initial approval will be based on the regional weighted average per diem (RWAPD) tuition rate for two years until such time that the required financial statements and reports of the new program are received by the Commissioner.

     Separate regional weighted average per diem tuition rates will be used for school-age programs and for preschool programs.

     The tuition rate for the third and subsequent years will be calculated using the standard methodology only if the actual full-time equivalent enrollment for the base year reported on the financial reports equals or exceeds the minimum number of full-time equivalent students required for program approval, as prescribed in Section 2007(c)(3) of the Regulations of the Commissioner of Education.

     If the reported base full-time equivalent enrollment is less than the required minimum enrollment, then the program will continue to receive the regional weighted average per diem tuition rate for the rate year until such time that the programís actual base year enrollment equals or exceeds the required minimum number of full-time equivalent students, as prescribed in Section 200.9(f)(2) of the Regulations of the Commissioner of Education.

     The RWAPD rates may be viewed at:      http://www.oms.nysed.gov/rsu/Correspondence/MethodologyLetters.htm