Guide for Completing School-Age Request for Reimbursement for1:1 Education Aides (other than full or half time) and ALL 1:1 Maintenance Aides, RNs, LPNs, and Interpreters f/t Deaf

 

Data Fields Description
STAC ID# Enter the 6-digit student STAC ID#, if known.
Student Name Enter the student’s full name. (Required)
Date of Birth Enter the student’s date of birth. (Required)
Education Provider Enter the name of the education service provider. Please be specific. (Required)
(For BOCES, indicate which BOCES.)
Provider Code Enter the education service provider SED code, if known.
Program Name Enter the name of the program the student attends. Please be specific.
Program Code Enter the 5-character STAC program code, if known. For students continuing at the same provider AND in the same program as the previous year, use the same program code as that year.   Examples: 9000-A, 9001-B,  9000-I.
Type of 1:1 Indicate which type of 1:1 is being requested. (Required)
Shared 1:1 Indicate No or Yes. (Required) If yes, indicate the number of students sharing the 1:1.
Component One must be indicated: Education Only, Maintenance Only, or Education & Maintenance.
Start/End Dates of 1:1 for Education

Enter the date the 1:1 is expected to begin and end service as per the student's IEP. (Required) Note: When the 1:1 is for less than the full time period of service entered on the original STAC record, two STAC records will be created -- one with 1:1 services/rates indicated and one without 1:1 services/rates indicated.

Hours Program Runs Enter the number of hours the program runs per day. (Full-day special classes usually run 5 to 6 hours.)  (Required)
Hrs/Day--Days/Week Student Attends Enter the number of hours per day AND days per week the student attends the program. (Required)
1:1 Days/Week Enter the number of hours per day AND days per week the student requires 1:1 services as per the student's IEP. (Required)
CSE District/Code Enter the CSE responsible district name. (Required) Enter the CSE SED district code, if known.
Date & Signature The CSE district superintendent must sign and date the Request form. (Required)
Start/End Dates of 1:1 for Maintenance: (Residential Students) Enter the date the 1:1 is expected to begin and end service as per the student's IEP. (Required) Note: When the 1:1 is for less than the full time period of service entered on the original STAC record, two STAC records will be created – one with 1:1 services/rates indicated and one without 1:1 services/rates indicated.
No. Hours Requested For both school days and nonschool days – Enter the number of hours per day  and the number of days per week the student requires 1:1 services during residential hours as per the student's IEP.
Salary and Fringe Benefits per Hour Enter the dollar amount of  salary and fringe benefits per hour that the 1:1 will be paid for services provided during residential hours. This information can be obtained from the school of placement where maintenance services are being provided. 
Contact Information This section should be completed as a reference source should questions arise.

NOTES

Note 1: 10-Month Public Excess Cost Placements: For students who attend district or BOCES programs and require 1:1 services as per the student's IEP, please note that 1:1 request forms are not required. The annualized cost for the 1:1 should be included in the total cost for special education services entered on the STAC. Requests received for students in these placements will be disregarded.

Note 2: Please contact the STAC and Medicaid Unit for a List of Schools for Which No 1:1 Aide Requests Will Be Processed. The tuition rates set by SED for those schools have been adjusted to include the cost for 1:1 services, thereby eliminating separate 1:1 add-on rates.

Note 3: Requests for RN, LPN, or Interpreter at those schools for which no 1:1 aides are allowed should continue to be submitted for processing, as 1:1 RN, LPN, and Interpreter rates continue to be in effect for these services.

Note 4: No 1:1 maintenance aide requests will be processed for students in Hard-to-Place (HTP) in-state maintenance programs.

 

Submit the 1:1 Request Form to:

NY State Education Department
STAC and Medicaid Unit
89 Washington Avenue – Room 514 West
Albany, NY  12234
Tel: 518/474-7116     Fax: 518/402-5047
Website: www.oms.nysed.gov/stac/ 
E-Mail: omsstac@nysed.gov

Last Updated: November 22, 2016