Oregon Department of EducationOffice of Learning/Student Services

255 Capitol St NE

Salem OR 97310-0203

To: LTCT Contractors

Re: Applications for LTCT Special Needs Funding

As per OAR 581-015-2572(4), a request to access the 5% set aside special needs funding may be submitted to the Department for unexpected, emergency situations. The contractor will need to substantiate the unexpected emergency, such as but not limited to, need for assistive technology, damage to school equipment, or a provision of unique services to support a student. Funding requests to support DHS identified “Target” students placed in LTCT programs automatically qualify to access these funds. Funding will be on a reimbursement basis, not included in the total contract amount. Request for reimbursement must be made on a quarterly basis.

To access the 5% Special Needs funds, please complete the attached application that includes:

  • a narrative of the unexpected needs warranting the provision of additional funding and how the need of service was determined (an appropriate evaluation by specialist was completed), how the services will be provided, and anticipated duration of those services; and
  • a budget proposal with anticipated budget detail for the use of the requested special needs funding for the current school year.
  • Maintaining a staffing level to meet the needs of your students --Amount requested must include the number of students, classrooms, teachers and educational aides and circumstances that exist to warrant your request to maintain the level of staffing requested.
  • Maintaining the number of instructional days from the current instructional year to the next biennium- Amount requested and the current number of school days currently offered? How many administrators, teachers, and educational aides will be impacted by a potential reduction?

An indirect rate of up to 3% may be applied to these funds, but a justification for the need to take an indirect amount must be provided.

Prior to submission of the application, LTCT contractors are encouraged to have a conversation with Sam Ko about their impending need and application. Please have all documentation sent to the Department of Education attention Sam Ko.

Documentation should be sent to:

Sam Ko

225 Capitol St NE

Salem, Oregon 97310-0203

Or email to:

Oregon Department of EducationOffice of Learning/Student Services

255 Capitol St NE

Salem OR 97310-0203

Application for Long Term Care and Treatment Special Needs Funds

OAR 581-015-2572(4)

LTCT Contracting ESD or District: ______Date: ______

Person Completing Application: ______Title: ______

Authorized Signature of LTCT SD/ESD Contractor: ______Phone #______

Name of residential/day treatment program official consulted: ______

Signature of residential/day treatment program official: ______

Request for Target Student Costs: Yes No If yes, Target Student SSID: ______

Please check the box below that best describes the reason for this request:

Maintaining a staffing level to meet the needs of your students

Maintaining the number of instructional days from the current instructional year to the next biennium

Other Emergency Request

Provide the following information: (up to one additional pageto assure enough detail is provided to explain the situation)
  • Description of unexpected emergent needs warranting the provision of additional funding.
  • If the request is to fund services, please identify the process used to identify the services, how the services will be provided, and the anticipated duration of the services.
  • If the request is to fund services checked in box above, please provide specific detail that relates to that bullet.
  • Include fiscal information with a tentative budget. Double click the budget section on the next page to launch Excel for fiscal data to be inputted.
  • An indirect rate of up to 3% may be applied to these funds, but a justification for the need to take an indirect amount must be provided.
(Do not include Personally Identifiable Information)

ODE USE ONLY:

Contract Administrator Signature/Date: ______Recommendation: ApprovalDenial

Program Manager Signature/Date: ______Action: Approved Denied

Form # 581-1454-P (4/15)

Form # 581-1454-P (4/15)