REQUEST FOR SELPA FUNDING FOR A SPECIAL EDUCATION
DAY CLASS FOR STUDENTS WITH SEVERE DISABILITIES
Note: This form to be completed by the agency requesting funding.
PART I - Identification:1. Operating Agency: / 2. Sending Agency:
3. Date of Request: / 4. Projected Start Date:
PART II - Program(s) and services being
transferred: / TO START / AT CAPACITY
# of Staff: / # of Students: / # of Staff: / # of Students:
A. Description of Program:
Office Use Only:
Date Received:Date Reviewed by Steering Subcommittee:
Date of Steering Committee Action:
Steering Committee Approval: / YES / NO
Date of Superintendents' Council Review:
PART III - Provide a detailed plan for the program that complies with Section 56207(a) and other procedural safeguards:
A. Assurances of compliance with Section 56207:
Instructions: Please provide a detailed narrative that reflects the planning process for the program change. Include in each section of the narrative the effect the proposed program will have on both students being served from other grades and students already in the current program, if any students are enrolled.
1. Section 56207 - pupil needs and the continuation of the current individualized education program for all affected students. If the proposed program involves a change in personnel or the site of service, please provide a detailed plan focusing on the following areas. Respond to examples only where applicable.
(a) Direct Instruction - examples include:
• The number (FTEs) and qualifications of all certificated and classified staff providing specialized instruction:
• Address how current employees will be affected by Section 44903.7:
(b) Related Services and Equipment - examples include:
• The number of (FTEs) and qualifications of all certificated and classified staff providing related services:
• The transfer of assistive technology or low incidence equipment:
(c) Facilities - examples include:
• A description of the location and classroom facilities and other specially modified facilities, if appropriate, including restrooms:
• The square footage of instructional space per student:
(d) Services from Non-Educational Agencies - examples include:
• The continuation of appropriate interagency agreements or other contracts:
(e) Opportunities for participation in the general education class and curriculum, if such participation were required by a student's IEP:
(f) If the program involves students with low-incidence disabilities, complete and attach the self-review guide in the California Department of Education Program Guidelines for the relevant disability category:
2. Section 56207(a)(5) - the maintenance of all appropriate support services. If the proposed program involves a change in personnel or the site of service, please provide a detailed plan focusing on the following areas:
(a) Number (FTEs), qualifications, and experiences of support staff. Examples include:
• Psychologists:
• Program specialists:
(b) Availability of other support services. Examples include:
• Finance services:
• Administrative support:
3. Section 56207(a)(7) - the involvement and representation of parents of all affected students and staff in the planning process. If the proposed program involves a change in personnel or the site of service, please provide a detailed plan focusing on the following areas. Respond to examples only where applicable.
(a) Involvement of parents. Examples include:
• The number of public meetings to which parents were invited and attended:
• The number of parents attending meetings:
• How and to whom invitations were transmitted:
• Evidence (such as minutes or agendas) that the information requested in numbers 1, 2, and 3 were discussed during those meetings:
(b) Involvement of staff. Examples include:
• Special and non-special education staff (such as teachers, administrators, and classified staff) who might be affected by the transfer in the planning process:
B. Procedural Safeguards Checklist:
• Timeline for holding IEP team meetings each affected student reflecting the new program
operator and any change in program configuration:
PART IV - Administrative Approval and Certifications of all three (3) entities:
Important Note: All entities involved in the program are advised to read the following requirements
prior to signing n the Certification boxes below.
1. The agency of service, the sending agency, and the Superintendents' Council of the Special Education Local Plan Area (SELPA) agree to the program funding.
2. In addition, by signing this form, all signatories assure that:
(a) Special Education instruction and related services provided by each affected LEA comply with all state and federal requirements;
(b) The level of services and the opportunity of the affected students to interact with the general school population is not diminished as a result of the program; and
(c) The program is consistent with all SELPA policies and the Local Plan.
3. If either the sending or receiving agency disagrees with the proposed transfer, the matter
will be resolved by an alternative resolution process.
CERTIFICATIONS
Sending Program Operator Name: / Date:
Authorized Signature: / Telephone:
Receiving Program Operator Name: / Date:
Authorized Signature: / Telephone:
Governing Body of SELPA: / Date:
Authorized Signature: / Telephone:
Sonoma County SELPA Program Transfer Form
Page 1 of 4
Adopted 12/5/11