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
a.
b. Is this the same provider that conducted the most recent evaluation for this student?
Yes
No
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
TO
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.)
(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