Approved Preschool Special Education Modification Application

The University of the State of New York
THE STATE EDUCATION DEPARTMENT
Office of Vocational and Educational Services
for Individuals with Disabilities
Albany, New York 12234
www.vesid.nysed.gov

The University of the State of New York
THE STATE EDUCATION DEPARTMENT
Rate Setting Unit
Albany, New York 12234
www.oms.nysed.gov/rsu

Approved Preschool Special Education

Program Modification Requests

(Click here for Word or PDF Format for printing)

April 2004

Approved Preschool Special Education
Program Modification Requests

This program modification request is divided into the following sections:

Section 1: General Agency/District Information
Section 2: Submission Requirements
Attachment A: Preschool Modification Request Assurance
Attachment B: Proposed Program Modification Chart

General Instructions

Complete a program modification request¹for proposed modifications to currently approved special education programs. See page 4 for the types of modification requests, A-J. Modification requests can be submitted for multiple modifications as long as the required documentation for each modification is included.

All applicants must complete Sections 1 and 2 and Attachments A and B.

Program related questions should be referred to the appropriate Special Education Quality Assurance Regional Office (see page 2).

Fiscal questions should be referred to the Rate Setting Unit (see page 2).

Submit the original modification request to the appropriate Special Education Quality Assurance Regional Office and a copy to the Rate Setting Unit, Attention: Preschool Modification Request (see page 2 for addresses).
It is the Department’s intent to process program modifications within 30 business days of receipt of a complete modification request. Contact the Special Education Quality assurance Regional Office and Rate Setting Unit before submitting a modification request to ensure that all required documentation is included.

Agencies and school districts may not implement the proposed modification request until written notification of approval by the State Education Department has been received. This approval will only be granted after the modification request is found to be consistent with applicable law and regulation as evidenced by a programmatic and on-site review, as appropriate, by the Special Education Quality Assurance Regional Office staff.

Separate procedures are required for transfer of ownership, possession or operation, or voluntary termination of an approved preschool (8 NYCRR 200.7(e)). Contact your Regional Associate at least 90 days prior to the intended effective date of such action.

_______________

¹Some modification requests may also require an application for an innovative waiver. The field memorandum and innovative waiver application are available at: http://www.vesid.nysed.gov/specialed/publications/preschool/home.html

VESID SPECIAL EDUCATION QUALITY ASSURANCE

WESTERN REGIONAL OFFICE NYS Education Department VESID Special Education Quality Assurance 2A Richmond Avenue Batavia, NY 14020 (585) 344-2002, ext. 420 (585) 344-2422 (fax)	HUDSON VALLEY REGIONAL OFFICE NYS Education Department VESID Special Education Quality Assurance 1950 Edgewater Street Yorktown Heights, NY 10598 (914) 245-0010 (914) 245-2952 (fax)
CENTRAL REGIONAL OFFICE NYS Education Department VESID Special Education Quality Assurance State Office Building 333 East Washington Street, Suite 527 Syracuse, NY 13202 (315) 428-3287 (315) 428-3286 (fax)	LONG ISLAND REGIONAL OFFICE NYS Education Department VESID Special Education Quality Assurance The Kellum Educational Center 887 Kellum Street Lindenhurst, NY 11757 (631) 884-8530 (631) 884-8540 (fax)
EASTERN REGIONAL OFFICE NYS Education Department VESID Special Education Quality Assurance Room 1623 One Commerce Plaza Albany, NY 12234 (518) 486-6366 (518) 486-7693 (fax)	NEW YORK CITY REGIONAL OFFICE NYS Education Department VESID Special Education Quality Assurance 55 Hanson Place, Room 545 Brooklyn, NY 11217-1580 (718) 722-4544 (718) 722-2032 (fax)
SPECIAL EDUCATION PROGRAM SERVICES AND REIMBURSEMENT BUREAU Rate Setting Unit NYS Education Department Room 304 EB Albany, NY 12234 (518) 474-3227 (518) 486-3606 (fax)

Agency Contact Person for Modification Request: _________________________________
Phone:____________________________ E-Mail Address _____________________________
Date Request Submitted: ____________ Proposed Date of Implementation: ___________

Approved Preschool Special Education
Program Modification Requests

Section 1: General Agency/District Information²

1. Legal Name of Agency/District
2. Doing Business As (DBA), if applicable
3. Mailing Address of Agency, School or District Administrative Office	Street
	City State Zip
4. Address of Program Site(s), if different (attach addresses of other sites, if applicable)	Street
	City State Zip
5. County and School District where Administrative Office is Headquartered	County
	School District
6. Agency's Federal ID Number		7. Agency/District 12-digit SED Code (required)
8. Telephone/E-mail Address of Administrative Office Area Code Number Ext. E-mail Address³:		9. Fax Number of Administrative Office Area Code Number
10. Name and Title of Chief Executive Officer/Chief School Official	Name
	Title
	Telephone		Fax Number	E-mail Address
11. Contact Person for the Educational Program	Name
	Title
	Telephone		Fax Number	E-mail Address
12. Contact Person for Fiscal Information	Name
	Title
	Telephone		Fax Number	E-mail Address

13. Complete the chart below for each currently approved preschool special education program:

Type of Program	Indicate Approval Status and Type of Modification Request
Special Class in an Integrated Setting (SCIS)	o Currently approved o No modification requested o Modification(s) *
Special Class (SC)	o Currently approved o No modification requested o Modification(s) *
Special Education Itinerant Services (SEIS)	o Currently approved o No modification requested o Modification(s) *
Multidisciplinary Evaluation	o Currently approved o No modification requested o Modification(s) *

*For each modification request above, indicate the reason(s) for request using the following letter code(s). Multiple letter codes may be used, as applicable.

A = Change in daily instructional hours; half to full-day, full to half-day⁴, other
B = Change in student-to-staff ratio⁵
C = Change in extended school year program within an approved program
D = Change in agency name
E = Change in location

F = Change in number or type of classes within an approved program
G = Add new site
H = Delete existing site
I = Other (e.g., Instructional Lunch, Language(s) served)

___________

²For multiple modification requests, only one copy of Section 1 is required.
³ This information is required and will be used for Department electronic mailings.
⁴Agency needs to be currently approved for both half and full-day classes, otherwise, the agency must submit an initial application for the new program.
⁵Modifications must be within an existing program and tuition rate, otherwise, the agency must submit an initial application for the new program.

Section 2: Submission Requirements

Submit Section 1 (see pages 3-4) with items 1-13 completed (General Agency/District Information).
Provide a narrative rationale and a description of each modification request.
Submit copies of the current preschool program approval letter(s) for which you are now seeking modification.
Submit Preschool Modification Request Assurance (Attachment A) and submit Proposed Program Modification Chart (Attachment B).
Submit required documentation for each modification request, as applicable, as described below:

Type of Modification Request	Required Documentation
A = Change in daily instructional hours; half to full-day, full to half-day, other	Assurance statement that includes a description of how program and services will continue to be provided as per IEP and without interruption Innovative waiver application, if applicable
B = Change in student-to-staff ratio	Assurance statement that includes a description of how program and services will continue to be provided as per IEP and without interruption Innovative waiver application, if applicable
C = Change in extended school year program	Assurance statement that includes a description of how program and services will continue to be provided as per IEP and without interruption School Calendar
D = Change in agency name	Copy of Certificate of Incorporation or Charter (where applicable)
E = Change in location [For programs relocating classes from one approved site to another, contact your Regional Associate to determine which documentation is required. For example, a Certificate of Occupancy or evacuation plan may be required even though the site is already approved.]	Copy of Certificate of Occupancy Fire Inspection Report Fire/Disaster Plan Evacuation Plan for Nonambulatory Children Copy of Building Lease (if building is rented or leased) Copy of Daycare License (where applicable) Copy of Floor Plan (for all program sites, blue print quality is not required) Site accessibility documentation from an architect, engineer or organization familiar with public buildings and ADA requirements⁶ For programs operating multiple facilities, submit a list of addresses for all facilities and indicate if the facility meets ADA accessibility requirements⁷
F = Proposed change in number or type of classes within an approved program	1. Requests for additional classes in an integrated setting – narrative describing regional need Documentation of regional need supported by letters from CPSE Chairpersons and Municipality Representatives Copy of Certificate of Occupancy Fire Inspection Report Copy of Daycare License (where applicable) Copy of Floor Plan (for all program sites, blue print quality is not required) Certification(s) for bilingual staff for new or expanded bilingual classes For programs operating multiple facilities, submit a list of addresses for all facilities and indicate if the facility meets ADA Accessibility requirements⁸ Innovative waiver application, if applicable
	2. Requests for expanded classes that include only preschool children with disabilities⁹ - written justification and supporting documentation must include: Description of the characteristics and needs of the preschool students to be served by the proposed program Documentation from school districts in the geographic region that identifies the preschool students with disabilities who require the proposed preschool special class program and that these students are unable to be appropriately served by the currently approved preschool programs in the geographic region. Student-specific IEPs may be requested by the SEQA Regional Office A plan describing how the proposed program will provide opportunities for students to participate in educational, extracurricular and other appropriate activities with students who are not disabled A letter from the District Superintendent of the BOCES region in which the proposed program is located or, in New York City, the Central Based Support Team, regarding the need for the proposed program Copy of Certificate of Occupancy Fire Inspection Report Copy of Daycare License (where applicable) Copy of Floor Plan (for all program sites, blue print quality is not required) Certification(s) for bilingual staff for new or expanded bilingual classes For programs operating multiple facilities, submit a list of addresses for all facilities and indicate if the facility meets ADA accessibility requirements¹⁰
	3. Requests for reduction in classes: Assurance statement that includes a description of how program and services will continue to be provided as per IEP and without interruption For programs operating multiple facilities, submit a list of addresses for all facilities and indicate if the facility meets ADA accessibility requirements¹²
G = Add New Site	Copy of Certificate of Occupancy Fire Inspection Report Fire/Disaster Plan Evacuation Plan for Nonambulatory Children Copy of Building Lease (if building is rented or leased) Copy of Daycare License (where applicable) Copy of Floor Plan (for all program sites, blue print quality is not required) Site accessibility documentation from an architect, engineer or organization familiar with public buildings and ADA requirements¹² For programs operating multiple facilities, submit a list of addresses for all facilities and indicate if the facility meets ADA accessibility requirements¹³
H = Delete Existing Site	Assurance statement with a description of how programs and services will continue to be provided as per IEP and without interruption

____________________

⁶ All preschool programs receiving public funds seeking or wanting to continue approval must provide accessible special education programs consistent with accessibility requirements of the Americans with Disabilities Act (ADA). This ensures that the continuum of services options for all preschool special education programs are accessible to students, parents, staff and visitors.
⁷ Programs operating multiple facilities must have at least one facility that meets ADA accessibility requirements. The Department reserves the right to request site accessibility documentation from an architect, engineer or organization familiar with public buildings to ensure that at least one facility is accessible to students, parents, staff and visitors.
⁸ See footnote 7
⁹ Refer to January 2000 field memorandum, Procedures for Application and Approval of Any New or Expanded Programs in Settings which Include only Preschool Children with Disabilities, for more detailed description of written justification requirements (www.vesid.nysed.gov/specialed/publications/preschool/expandprog.htm).
¹⁰See footnote 7
¹¹ See footnote 7
¹² See footnote 6
¹³ See footnote 7

Attachment A

Preschool Modification Request Assurance

School Name ___________________________

FORM G/I - General Information

Legal Name of Agency: _____________________________________________________

A/K/A, if applicable: ________________________________________________________

Superintendent/Executive Director Name: __________________________________________

Mailing Address: __________________________________________________________

______________________________________________________________________

Telephone: __________________________ Fax: _____________________________

Contact Person for this modification request (Name, Title, Phone Number, E-mail): ______________

______________________________________________________________________

I declare that I have examined the completed modification request application, and it is a true and complete statement of the required information. If approved, I assure that the health and safety of students will not be compromised at any time for all modification requests included in this application.

If this modification request application also requires construction or renovation, I understand that there will be no requests made to the Division of the Budget for any cost screen waivers for preschool programs, as the Department does not adjust preschool tuition rates for capital renovation/construction projects¹. Furthermore, I understand that all the associated project costs should be reported in the program cost centers affected by the renovations, and these costs will be funded through the tuition rate(s) to the extent allowed by the cost screen components of the rate setting methodology.

Signature ___________________________________ Date ____________________________
Executive Director

___________________

¹Capital projects refer to construction, renovation and acquisition of real property for educational purposes, including administrative and ancillary space and facilities used to support educational functions.

Proposed Preschool Special Education Program Modification Chart

Name of Program: ___________________________ Agency Code: ________________________

Type of Program (Program Code): Special Class (9100, 9115), Special Class in an Integrated Setting (9160, 9165)

Instructions: For each site where there is a proposed change, enter currently approved information in Row 1 consistent with the last approval letter and proposed modification in Row 2. Make duplicate copies of chart as needed.

Program Site Address

County of
Location

Site Code

Licensed Day Care

Program Code

Overall Student/
Teacher/Para
Ratio

Special Ed.
Student/
Teacher/
Para
Ratio

Bilingual Language

Half-Day

Full-Day

School Year Code

Yes

# of Classes

# of Hours

2-Mo.

10-Mo.

Totals

NOTE: Half-day/full-day classes are approved to provide 2.5/5 hours of instructional time respectively, unless daily instructional hours are noted in the full-day column.

The "Overall Class Ratio" and "# of Special Ed. Students or Special Ed. Ratio" columns for special class in an integrated setting programs represent respective numbers for those classrooms that are:

made up of no more than 12 preschool students (an innovative waiver may be submitted to serve more than 12 preschool students) including both students with and without disabilities and employing a special education teacher and at least one paraprofessional in the classroom; or
made up of up to 12 preschool students with disabilities, a special education teacher and at least one paraprofessional in the same space with a preschool class of students without disabilities and their own teacher.

______________________

¹Row 1- Currently Approved
²Row 2 - Proposed Modification