Evaluation Form Instructions



(Request for Commissioner’s Approval of Reimbursement for the Cost of Evaluations Pursuant to Section 4410 of the Education Law)
STAC CHILD ID The unique 6-digit STAC ID number assigned for each child processed by STAC. This identifier remains the same throughout the child’s educational career. Please enter if known.
1. Name of Child Be accurate and consistent. Use of nicknames can lead to duplicate ID numbers. If a child has been adopted, a copy of the adoption order should be attached to the STAC form before the child’s name can be changed on the system.
2. Date of birth Indicate the child’s birth date. A correction in date of birth requires a copy of the child’s birth certificate.
3. Gender of child Indicate the gender of the child by checking the appropriate box.
4. Social Security Number Although not a required field, please enter if known.
5. SIS Child I.D. Student Information System Child I.D. Include if applicable.
6. Racial/Ethnic Category Indicate the racial/ethnic category by checking the appropriate category.
7. Disability Indicate if the child is, or is not, a preschool student with a disability as defined in the Regulations of the Commissioner.  If, for any reason, a student is withdrawn from the CPSE process before the CPSE makes a determination regarding the existence of an educational disability, the district should check the “Non-Disabled” box.
8a.  Public School District that has CPSE  Responsibility Public school district of the child’s current location (where the child resides).
8b. County of Child’s Current
Location (where child resides)
The county of the child’s current location.  This is the county that will be reimbursed by SED.
8c. County at Time of Child’s Placement in Foster Care or in Temporary Housing by Local Social Services agency. The county where the child lived at the time the child was placed in foster care or temporary housing or became a resident in a facility licensed or operated by another state agency.  This should be left blank if not applicable.
9. SED Approved Evaluator Enter the name of the agency that conducted the evaluation.
10. Evaluation Components for Bilingual Evaluations and Evaluations Conducted in Other Modes of Communication Only Provide the month and year when each component of the evaluation was completed. These dates will be used to determine the rate of reimbursement. Place a check mark (√) on the line for any component(s) of an evaluation that required an individual (translator) in addition to the evaluation professional or the use of a bilingual professional.
11.  If a translation of a summary report has been prepared and transmitted to the parent(s), indicate the cost. If a translation of the evaluation documentation has been prepared and transmitted to the parent(s), indicate the cost. The summary report is to be completed on a form developed by SED.  In addition, the Regulations of the Commissioner require that a copy of this report be given to the parent.  Enter the dollar figure (whole dollar amounts) on the line provided for costs associated with translating the summary report of the evaluation into the parent’s preferred language or other mode of communication. This item is completed only if translation of the actual documentation of the evaluation into the parents’ preferred language or mode of communication has been done at the parent’s request.  Use whole dollar amounts.  NOTE:  Translation costs are not reimbursable if the child received a bilingual evaluation since the rates for bilingual evaluation include such costs.
12.  Certification of Evaluation The CPSE Chairperson must complete this field.
13.  Municipality Signature Section All requests submitted to SED must be authorized by the Municipality Representative. 
Person completing this form (Item on back of STAC-5) A name and telephone number should be provided here.  This will allow the STAC Unit staff to resolve any problems or questions about the STAC-5 in the most timely manner.
Last Updated: July 25, 2014