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Form J/A 07-9015: APPLICATION for APPROVAL of JULY/AUGUST NON-SPECIAL CLASS SERVICE(S) (Program Code 9015)

PLEASE NOTE: SCHOOL DISTRICTS ARE REQUIRED TO SUBMIT ANNUALLY A COMPLETED APPLICATION FOR EACH 9015 NON-SPECIAL CLASS PROGRAM          IT PROPOSES TO OPERATE DURING A JULY/AUGUST EXTENDED SCHOOL YEAR.

Please complete every question in this application.   Please complete one of these applications for each Non-Special Class program type you plan to operate under Program code 9015.  The STAC and Special Aids Unit will use the information on this form as the basis for the review of student STAC forms.  The Rate Setting Unit will use this information to establish half hour rates for each Non- Special Class Program Type.
 
PART ONE:  GENERAL INFORMATION / NARRATIVE

1. Name of school: _____________________________________________________

SED School Code:  _________________________________________________

2. Name of the specific extended school year service(s) for which you are seeking approval (CHECK ONLY ONE):

Non-Special Class Programs (9015)       
[    ] Related Services Only     [    ] Specialized Instruction Only
[    ] Specialized Instruction with Related Services [    ] Home/Hospital Instruction

3. Address:            ___________________________________________________________
   (Street and/or Post Office Box)
   ___________________________________________________________
   (City)                                                   (State)             (Zip)
   ___________________________________________________________
   (County)
              
4. Telephone: _____________________________ Fax: ________________________
   
   
5. E-mail address: ______________________________________________________
    
6. Contact Person: ______________________________________________________
    
   Title: ______________________________________________________________
   
   
7. Dates of this/these service(s):           Beginning 7/_____/07 Ending 8/____/07
                                                  
8. How many New York State students are expected to be served in this program during July/August?  ______
   
9. What related services will be provided?  ___________________________________

_________________________________________________________________

10. Briefly describe the program model (include where and how instruction and/or related services will be provided) Attached additional pages if necessary.____________________________________________________________
    ____________________________________________________________________
    ____________________________________________________________________
    
    
11. Draw a box around all the dates on the calendar below to show the days of program’s operation.

                JULY    2007                                                               AUGUST    2007

          2        3          4         5           6                                                     1          2           3 

          9       10        11       12       13                               6         7          8          9          10
  
         16      17       18        19         20                            13        14        15        16        17

         23      24       25        26         27                            20        21       22        23         24

         30      31                                                                27       28        29        30

PART TWO: BUDGET

Instructions for Completing the Non-Special Class Budget for programs approved to operate during July and August under Section 4408 of the Education Law – Program code 9015

The Reimbursable Cost Manual (RCM) is available by calling (518) 474-3227 or at www.oms.nysed.gov/rsu/home.html. The RCM defines items to be included in specific expense accounts listed on the budget schedules and is the basis for determining reimbursable costs on desk audits and field audits.

SCHEDULE 1: Projected Personal Services
 In Schedule 1, report projected salaries of Non-direct Care (Administration/Facility) and Direct Care (Instructional, and Related Services) staff by job classification using the applicable job titles listed in the table below as a guide. The total salaries must reconcile with the projected expenditures reported on line 1, "Salaries", on Schedule 2 "Projected Expenditures".

 The FTE should be rounded to two decimal places (.00). The standard formula for calculating an employee’s full-time-equivalent (FTE) is as follows:
 

Schedule 1
Non-direct Care – Administration/Facility

SCHEDULE 2: Projected Program Expenditures

• Programs that are approved to provide services that are not special class programs must complete this budget in order to receive State aid for this approved program.
• Report projected expenditures in whole dollar amounts.
• Projected expenditures must be reasonable, necessary and directly related to the 9015 program.

Non-Special Class Budget – Program 9015

Schedule 2: Projected Program Expenditures – Do not leave any line item blanks -- (indicate – 0 – or N/A)

Direct Care – Instructional, Social Services, Related Services (1)

(1)  For each Direct Care position listed, please provide the number of one half hour sessions of service to be provided in total for each position type.  This includes only direct contact time with students.

ASSURANCES (Please complete and attach to each Non-Special Class Program application submitted to the Department  for review and approval)

This special education program and service(s) will be provided in accordance with Section 4408 of the Education Law and Part 200 of the Regulations of the Commissioner of Education and will include but not be limited to:

• The special education program and services and staff will meet all certification and education standards pursuant to Part 200 and Part 80 of the Regulations of the Commissioner of Education.
• The special education program/service(s) must operate for 30 days during the months of July and August only and this is the maximum number of days the State will reimburse programs for costs incurred during this time period.
• All instructional and related services will be provided consistent with each student’s Individualized Education Program (IEP).
• Publicly funded school-age students will not be admitted into the special education services without an IEP from the Committee on Special Education (CSE).
• Parents of students attending programs and services governed by this section will not be asked to make any payments for allowable costs for students placed according to NYS procedures.
• Programs will maintain appropriate accounting documentation and provide necessary financial reports when requested.
• The confidentiality of personally identifiable data, information or records pertaining to a student with a disability will be maintained in accordance with 34 CFR §§300.611 - 300.626 (August 14, 2006) Implementing Regulations of the Individuals with Disabilities Education Act of 2004, the Family Educational Rights and Privacy Act (FERPA) Regulations (34 CFR Part 99 - April 11, 1988) and 8NYCRR 200.5(e)(2).
• All programs and services will be provided in non-sectarian, neutral settings.
• To the maximum extent appropriate, students with disabilities will be educated with students who are nondisabled [34 CFR §300.114 (a)(2)(i)].
• Programs will comply with all applicable fire and safely regulations of the State and municipality in which the program/service(s) is located.
• The program will only be reimbursed for the number of half-hour direct contact sessions requested in Schedule Two of the Budget Section which are approved by the State Education Department.

I, the undersigned, attest that the assurances provided are accurate regarding these services.

 Name ________________________________ Signature ____________________________

Title  _________________________________________ Date _______/_______/ 2007

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