TEXAS EDUCATION AGENCY
1. name of local educational agency (lea)/fiscal agent / Division of IDEA Coordination / county-district no.
region
Application for Approval of Residential Placement
Fiscal Year 2011-12
/TEA Use Only
/ High Cost Funds application submittedAuthority for Data Collection:CFR 300.325, CFR 300.146, CFR 300.500, TEC §29.008, and 19 TAC §89.61.
Planned Use of the Data:To determine the cost of residential placement of students with disabilities and ensure that this request for services is in accordance with state and federal laws and rules.
2.Enter an “x” in the appropriate box:
/ New (application submitted first time for this student) / STAMP-IN DATE
/ Continuing (application submitted for this student to continue services/placement) / (must be entered by ESC)
/ Amendment/Cost Revision (amendment for changes in approved services/costs)
3.Will the LEA submit a HCF request? / Yes No
4.Student's Name ______-__
5.Date of Birth (mm/dd/yyyy) / / / /
6.Primary Disability:
Autism / Emotional Disturbance / Intellectual Disability (MR) / Other:
7.Sex: / Male Female
8.Primary Language
9.Dates of Residential Placement: / / / / / to / / / /
10.Number of years in residential placement to date?
11.Enter name of Residential Facility: / Phone Number / ( / )
Address of Residential Facility where student resides or will reside:
Facility’s contact name: / Phone Number / ( / )
12.Enter name, title, phone number and email address of LEA special education contact:
Name / Title / Phone Number / ( / )
Email address:
13.Enter an “x” to indicate the appropriate authority, type contact’s name, title and phone number:
Mental Retardation Authority (MRA)Mental Health Authority (MHA)
Name / Title / Phone Number / ( / )
1
SAS-111R98
TEXAS EDUCATION AGENCYname of local educational agency (lea)/fiscal agent / Division of IDEA Coordination / county-district no.
student name
Statements of Assurance for Residential Placement
If the student's Local EducationAgency (LEA) of residence is a single district or a member in a Special Education Shared Services Arrangement (SSA), the signature of the LEA's superintendent or fiscal agent superintendent ensures that the LEA accepts and agrees with the following assurances:The responsible LEA assures the regional Education Service Center (ESC) of the following:
1.For students who either have been or will be placed in a private residential placement, the Admission, Review, and Dismissal (ARD) committee has:
- formulated a current Individualized Education Program (IEP) for the student, and
- determined that the necessary services cannot be provided by the LEA, but can be provided by the residential facility.
3.The ARD committee has:
- determined that the selected residential facility is the most appropriate educational environment to meet the student's educational and related service needs in the Least Restrictive Environment (LRE);
- contacted other appropriate state agencies to determine if services and/or financial assistance for the student are available;
- ensured that a plan has been developed by the residential facility, the LEA, and other public agencies which ensures the acquisition of credit toward graduation and completion of a program designed specifically for the student;
- determined that this placement is cost effective relative to other placements considered; and
- developed a plan with specific timelines and criteria for returning the student to the local program. This plan will remain at the LEA in accordance with 19 Texas Administrative Code §89.61(a)(4)(C) Contracting for Residential Educational Placements for Students with Disabilities.
- develop a contract with the selected residential facility;
- advise the parents of the specific arrangements between the sending LEA and the residential facility, including information about the parents' responsibility for items such as clothing, medical treatment, allowances, and non-educational supplies;
- reimburse the residential facility on a monthly basis unless a different payment period is agreed upon by the LEA and residential facility; and
- education with peers without disabilities is provided for the student;
- provisions will be made for participation of the student in nonacademic and extracurricular activities with students without disabilities;
- personnel are aware of any potential harmful effect on the student and review the quality of services provided on a regular basis; and
- student is making educational progress when continuing in the residential placement.
Certification
We hereby certify that the information contained in this document is true and correct to the best of our knowledge, and that we accept and agree to these Statements of Assurance. Services provided under this section may not be used for a student with disabilities who currently is placed or who needs to be placed in a residential facility primarily for non-educational reasons. We also certify that parents, MRA/MHA staff, and LEA staff were involved in the development of this application. We further certify that any ensuing program and activity will be conducted in accordance with federal and state laws and regulations. It is understood by the applicants that this application constitutes an offer, and if approved by the Texas Education Agency or renegotiated for approval, will form a binding agreement.typed name and title of authorized
representative of mra or mha* / Check one:
MRA
MHA / date / telephone / original signature
*To be signed by the authorized representative of the MRA or MHA; i.e., the superintendent of a state school, the director of a state center, the executive director of a community center, only as verification that staff were consulted regarding services for the student named in this application.
typed name and title of authorized
representative for lea/fiscal agent** / date / telephone / original signature
**To be signed by the superintendent of a single member LEA or the fiscal agent LEA/Education Service Center (ESC) for the special education SSA. If anyone other than the executive director or superintendent signs this application/amendment, attach a letter of authorization.
TEXAS EDUCATION AGENCY
1.name of local educational agency (lea)/fiscal agent / Division of IDEA Coordination / county-district no.
student name / TEA USE ONLY
Residential Placement / TEA-EducationServices
Cost Breakdown / $ ______
2.All services/costs listed below must be included in the Individualized Education Program (IEP), the Schedule of Services, and the contract with the residential facility (RF). TEA will calculate the cost of the education services.
This form must be completed regardless of the funding source. Please consult the State Funding Division’s Summary of Finances website for information on Adjusted Basic Allotment (ABA): .
3.Indicate with an “X” how education services are provided in the residential facility.
Education services are provided by the ______(LEA). If education services are provided by the LEA in which the facility is located, an agreement for special education services must be provided. A sample agreement is provided as an attachment to the Specific Instructions (for completing the cost breakdown.)
Facility provides the education services. (Education Services funding amounts are derived through theABA X 1.7 weight = total.)
4.Provide an estimate below to calculate the education services for the total cost estimate.
LEA ABA $______x 1.7 = ______for the residential application contract period.
education services
5.Related, Speech, Supplemental, and Support Services Provided
Complete the columns below for appropriate services provided during the approved period aligned with the Schedule of Services.
Round to nearest dollar in the Subtotal columns.
8.Total for Related, Supplemental, and Support Services Provided
9.Residential Services Provided (not to exceed $242.85/day)
Multiply the daily rate by the total days. Complete each column with appropriate information. Round to nearest dollar in the Subtotal column.
10. Daily Rate / Total Days / Subtotal / Agency Use Only11. Estimated education services
12. Total Cost for residential placement
13.Amounts have been checked for accuracy.Yes No
14.Copy of this completed form has been provided to the residential facility. Yes No
15.TEA USE - CALCULATION ONLYFEDERAL FUNDS / Related Services Cost / Residential Care / Total Approved Cost
IDEA-B Formula (available portion of 25% set aside)
IDEA-B Discretionary
STATE/LOCAL FUNDS
Local Tax Share
Total Approved Funding for Residential Placement
State FSP (education services cost only)
TEA Total Approved Cost/AWARD
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