Form Preschool Stac-1 - Request For Commissioner'S Approval Of Reimbursement For Services For Students With Disabilities - The University Of The State Of New York, The State Education Department

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PRESCHOOL STAC-1

The University of the State of New York

Public School District that has Committee on Preschool

T H E S T A T E E D U C A T I O N D E P A R T M E N T

Special Education Responsibility

(Updated February 2014)

Albany, New York 12234

Request for Commissioner’s Approval of Reimbursement for Services for Students with Disabilities

Pursuant to Section 4410 of the Education Law

County of Child’s Current Location (where child resides)

STAC-ID

County at Time of Placement in Foster Care or in Temporary Housing or in a

residential facility licensed or operated by another State Agency

STUDENT INFORMATION

Service Provider for Special Class, SCIS or SEIT

Last Name

First Name

Middle Initial



b. Is this the same provider that conducted the most recent evaluation for this student?

Yes

Date of Birth (mm/dd/yy)

Student Identification Number

Gender

Name of Program

(if applicable)



Female

Male

________/________/_________

RACIAL ETHNIC CATEGORY OF

RELATED SERVICE OR SEIT PROVIDER

TYPE OF RELATED

HRS PER

DAYS

PLACEMENT TYPE

STUDENT

SERVICE

DAY

PER WK

 Hispanic or Latino

Approved Program (DSPRE)

 Special Class

Not of Hispanic Origin:

 Special Class Integrated Setting

 American Indian or

(SCIS)

Alaskan Native

 Asian or Pacific Islander

Related Services and/or SEIT (DSSEI)

 Black or African American

 Related Services only

 Native Hawaiian or other

 Special Education Itinerant

Pacific Islander

Teacher and/or SEIT plus

 White

Related Services

 Two or more Races

(see explanation on reverse side)

SERVICE

FROM

HRS. PER

DAYS PER

SEIT OR RELATED SERVICES

NUMBER OF HALF

RATE PER HALF

TRANSPORTATION

INFORMATION

DAY

WEEK

HOUR SESSIONS

HOUR SESSION

(Mo./Day/Yr.)

INDIVIDUAL

GROUP

Education or SEIT

___/___/___ ___/___/___

Dates of Transportation

Related Service 1

Indicate Rel.Serv Type

___/___/___ ___/___/___

Related Service 2

Indicate Rel.Serv Type

___/___/___ ___/___/___

Related Service 3

Indicate Rel.Serv Type

___/___/___ ___/___/___

Total Cost of Transportation

Related Service 4

Indicate Rel.Serv Type

___/___/___ ___/___/___

$__________________.______

Related Service 5

Indicate Rel.Serv Type

___/___/___ ___/___/___

AUTHORIZATION OF PLACEMENT: I certify that the preschool student with a disability herein named is being provided the educational services indicated and that such services have been

recommended by the Committee on Preschool Education and the child is eligible for such placement in accordance with the Regulations of the Commissioner and Section 4410 of the Education Law.

Signature:_______________________________________________________

_______________________

AUTHORIZED REPRESENTATIVE OF THE BOARD OF EDUCATION-BOU

Date of BOE Authorization