NYSED Navigation • NYSED HOME •  SEARCH • TOPICS A-Z • CONTACT NYSED
 

Vocational and Educational Services for Individuals with Disabilities (VESID)
Special Education and Vocational Rehabilitation Services

---

                          

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.vesid.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

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

 

Available in Word or PDF format for printing

  

 

 

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.vesid.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)]

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

RESOURCES TO ASSIST APPLICANTS

• Program related questions should be referred to staff in the appropriate Regional Office for Special Education Quality Assurance: http://www.vesid.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.vesid.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.vesid.nysed.gov/specialed/publications/lawsandregs/coverpage.htm.
   

• Part 100 of the Regulations of the Commissioner of Education is available at: http://www.emsc.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 VESID website at:  http://www.vesid.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.vesid.nysed.gov/specialed/publications/home.html

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

http://www.vesid.nysed.gov/specialed/sitemap.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

---

 

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
 

1.  Legal Name of Agency/Private School
2.  Doing Business As (DBA), If applicable
3.  Type of Program (check all that apply)  o Day School             o Residential School             o 10-Month Program             o 12-Month Program
4.  Mailing Address of Agency		Street
		City                                          State                                Zip
5.  Address of Program Site(s), if different   (Please duplicate this page as   necessary.)		Street
		City                                          State                                Zip
6.  County and School District where Administrative Office Is Headquartered (applies to NYS applicants only)		County
		School District
7.  Agency’s Federal ID Number:                                                                                Agency’s Charity Registration Number for Nonprofit Organizations from the Department of State: (NYS applicants only)			8.  Agency SED 12 digit code (if known)
9.  Telephone Number of Administrative Office       Area Code             Number                    Ext.             Email Address*			10.   Fax Number of Administrative Office
11. Name and Title of Chief Executive Officer/Chief School Official	Name
	E-mail address
	Telephone			Fax Number
12. Contact Person for Education Program	Name
	E-mail address
	Telephone			Fax Number
13. Contact Person for Fiscal Information	Name
	E-mail address
	Telephone			Fax Number

 

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

 Private Entity:          

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

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

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

 

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

a) o  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) o  Nonprofit (Education Corporation or Not-for-Profit Corporation)

o  Education Corporation

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

o  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)

 

---

 

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