13. Entity Type: (Check only one, Private or Public)

Private Entity:

Public Entity:

14. If Private Entity: (Check only one)

For further information on consents and charters, contact the Office of Counsel at (518) 473-8296.

15. Attach a list of the related entities (less than arms length pursuant to 200.9(a)(14)) that operate any programs approved under Articles 81, 85, or 89. Also include names of staff members who are providing services to these related entities operating approved programs who will also provide services to these programs seeking initial approval.

 Complete the chart below for each currently approved preschool special education program and/or for each program for which you are now seeking approval:

• Indicate the name and title of any individual from the evaluation site who will have direct supervisory responsibilities for the Multidisciplinary Evaluation process including staff; provide the supervisor’s resume to document an appropriate level of experience. Supervision requirements are outlined in Part 80 (http://www.highered.nysed.gov/tcert).

• Describe how any specialized evaluation services will be arranged and who will conduct them.

• Attach copies of any agreements your agency has for specialized evaluations. (Section 4410.9(b) of Education Law)

• Describe how bilingual evaluations will be conducted.

• Attach copies of certification and required experience of the bilingual evaluator.

• Provide site accessibility documentation from an architect, engineer or organization familiar with public buildings and program accessibility requirements of the Americans with Disabilities Act. ²

• Indicate how the preschool special education program will provide services to preschool students with disabilities in the least restrictive environment.

• Describe how programming and curriculum will incorporate each student’s IEP goals and objectives and developmental levels.

• For SEIS programs, describe the method of coordinating the provision of related services when included on the preschool student’s IEP.

• Provide a plan for parental involvement, as appropriate.

• For SCIS and SC programs, provide site accessibility documentation from an architect, engineer or organization familiar with public buildings and program accessibility requirements of the Americans with Disabilities Act. ³

• Provide the plan for staff supervision, including employed and sub-contractual staff. Indicate the name and title of any individual who will have direct supervisory responsibilities for the Preschool Program process including staff; provide the supervisor’s resume 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 certificate valid for administrative and supervisory service should be indicated on the administrator or supervisor’s resume.

• If applying for a bilingual program, indicate how the program will provide bilingual instruction to students recommended for bilingual services. Submit copies of certification for bilingual staff.

• If the special class in an integrated setting is in an early childhood program operated by another agency, indicate the name of the agency and submit a copy of the collaborative agreement with that agency.

___________________

All preschool special education programs and services shall be provided in accordance with section 4410 of Education Law and the Part 200 Regulations of the Commissioner and shall include but not be limited to the following:

I, the undersigned, have read and attest that the initialed assurances indicated above as required in this application are accurate and will be fulfilled with regard to the preschool special education program(s) for preschool students with disabilities operated by this agency/district.

List each member of the professional supervisory or administrative staff, related/support services staff, educational services staff (teacher/paraprofessional), their certification or licensure and their allocation of time for the preschool special education program(s) proposed. Time that these staff members spend in the provision of services in other programs including, but not limited to, the early intervention program, school-aged special education program or preschool related services should be reported in the "Hrs. Per Week for Other Programs" column.

** Attach copies of each professional’s certification and/or licensure and bilingual staff certifications

Indicate the proposed hours of operation for this program:

Indicate on line 1 in the table below the total number of preschool students with a disability this program proposes to serve who meet the criteria in Section 200.1(mm) of the Regulations of the Commissioner. Identify on lines "a" through "h" the proposed number of students, if any, who meet the eligibility criteria identified in Section 200.1(mm)1(ii) of the Regulations. Note that the total on line 1 may exceed the sum of lines "a" through "h" because each student may not be labeled with a specific disability.

On Line 2, enter the number of instructional days in the proposed SEIS program calendar.

On Line 3, enter the standard hours per week that a full-time teacher works, either in this program or in other preschool programs operated by your agency/district. This number may not be less than 35 hours per week.

On Line 4, enter the billable hours for the students reported on line 1. Billable hours are defined as time allotted for providing direct and/or indirect special education itinerant services in accordance with the student’s IEP on an enrollment basis in accordance with Section 175.6(a)(1) and (z) of the Regulations of the Commissioner. Direct services are scheduled special education sessions with the student. Indirect services are scheduled consultations with the student’s day care/regular education teacher. Total billable hours must be at least two (2) hours per week for each student.

Indicate in the table below the proposed student/staff ratio for each special class in an integrated setting. Copy and submit as an additional page if more than 7 classes will be offered in this program. Identify whether classes are half day (not less than 2 ½ hours of instruction per day) or full day (more than 2 ½ hours of instruction per day) by indicating H for half day and F for full day.

Indicate on line 1 in the table below the total full-time equivalent (FTE) number of preschool students with a disability this program proposes to serve who meet the criteria in Section 200.1(mm) of the Regulations of the Commissioner. Identify on lines "a" through "h" the proposed FTE number of students, if any, who meet the eligibility criteria identified in Section 200.1(mm) of the Regulations. Note that the total on line 1 may exceed the sum of lines "a" through "h" because each student may not be labeled with a specific disability. Identify whether students are half day (not less than 2 ½ hours of instruction per day) or full day (more than 2 1/2 hours of instruction per day) by indicating H for half day and F for full day.

Full time equivalent (FTE) for SCIS programs must be calculated in accordance with Section 175.6 of the Regulations of the Commissioner.

On Line 2, enter the total number of full-time equivalent (FTE) students without a disability to be served in this program.

On Line 3, enter the number of instructional days in the proposed SCIS program calendar.

On Line 4, enter the standard hours per week that a full-time teacher works, either in this program or in other preschool programs operated by your agency/district. This number may not be less than 35 hours per week.

Identify whether classes are half day (not less than 2 ½ hours of instruction per day) or full day (more than 2 ½ hours of instruction per day) by indicating number in appropriate column indicating H for half day and F for full day.

• Report projected expenditures in whole dollar amounts.

• In Schedule 1, projected program expenses for both students with disabilities and students without disabilities should be combined for reporting purposes.

• Projected expenditures must be reasonable, necessary and directly related to the SCIS program.

• For private providers, on the "Other (Specify)" line, report expenditures not listed on lines 8 through 27. Attach detail for any amount listed here.

• For BOCES, the expenditures indicated on the budget may not be compatible with expense classifications as defined by the Uniform System Of Accounts. Expenditures, which are expected to be incurred but are not specifically listed on the budget, should be included in the "Other (Specify)" line. Attach detail for any amount listed here.

• For public schools, the expenditures indicated on the budget may not be compatible with expense classifications as defined by the Uniform System Of Accounts. Expenditures, which are expected to be incurred but are not specifically listed on the budget, should be included in the "Other (Specify)" line. Attach detail for any amount listed here.