To view the description of the report including instructions please click here.
The following types of schools may use this form to request §4410(b) vendor funding from school districts that have Committee on Preschool Special Education (CPSE) or Committee on Special Education (CSE) responsibility for students with disabilities. The use of this form is not mandatory, and schools may develop and use their own form for requesting §4410(b) vendor funding.
| Section 1: Approved Special Education Program Requesting §4410(b) Vendor Funding | ||
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(Enter 12-digit SED Code Below) |
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| SCHOOL NAME
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| ADDRESS (include building name, room number, or mail stop information)
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| CITY
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STATE
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ZIP
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| Contact Person of Approved Special Education Program Requesting Vendor Funding | |
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| NAME/TITLE
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| TELEPHONE (include Area Code)
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FAX
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IMPORTANT NOTE: NYSED recommends that LEAs receive this form by November 25, 2022, or the subsequent date established by the LEA, in order to provide accurate §4410(b) vendor funding to approved special education programs for the 2023-2024 school year.
| Section 2: Local Education Agency (LEA) Requested to Issue Vendor Funding. (For students placed in out-of-State schools by the courts or State agencies, the LEA is the school district in which the student resided at the time of such placement.) | ||
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| (Enter 12-digit SED Code Below) |
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| LOCAL EDUCATION AGENCY NAME
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| ADDRESS (include building name, room number, or mail stop information)
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| CITY
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STATE
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ZIP
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| Section 3: Child Counts for Students Residing in LEA Identified in Section 2. Report the count of students with disabilities ages 3-5 in part A and the count of students with disabilities ages 6-21 in part B. Age, enrollment, and type of service provided are as of October 5, 2022. |
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| A | Students with disabilities ages 3-5 Age, enrollment, and type of service provided are as of October 5, 2022 Each student should be included only once in category 1, 2, or 3 |
Count of SWDs Ages 3-21* | Count of SWDs Ages 3-5 * |
| 1 | Number of preschool students (ages 3-4) provided related services only. Do not report students in this line if they are also receiving other preschool special education programs. | ||
| 2 | Number of preschool students (ages 3-4) provided a preschool special education program, which includes Special Education Itinerant Teacher (SEIT) services and/or full- or part-time special class or special class in an integrated setting services. These students may also be receiving related services. Please note that if students receive services from more than one provider, only the provider that is designated as the "coordinating provider" may report the student on this form. | ||
| 3 | Count of school-age students (ages 4-5) attending programs for school-age children. | ||
| *Note: Students who are ages 3-5 are eligible to be counted under both Ages 3-5 and Ages 3-21 | |||
| B | Students with disabilities ages 6-21 Age and enrollment are as of October 5, 2022 |
Count of SWDs Ages 6-21 |
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| 1 | Count of students with disabilities, ages 6-21 | ||
I have reviewed the information reported in this form and certify that this is a complete and accurate count of students with disabilities who were placed in this program by the local education agency listed in Section 2 of this form as of October 5, 2022. I certify that students placed in this school were served in a manner consistent with their respective Individualized Education Programs. A list of the names of the students reported in Section 3 will be submitted to the local education agency with this form and marked “confidential.”
Form must be signed and dated by Chief School Administrative Officer. Please print out a printer friendly version of this form in Word or PDF.