Request for STAC Forms
The following STAC forms are available in PDF format. Click on the form link below.
Forms Requiring Personally Identifiable Student Information
Upload completed forms to SED File Transfer Manager (FTM) “inbasket”. After uploading, send a notification email to OMSSTAC@nysed.gov with your agency's SED Code and the complete filename.
STAC-1 Forms:
- Preschool STAC-1
-
Preschool Request for Commissioner's Approval of Services
for students with Disabilities - School Age STAC-1
-
School Age Request for Commissioner's Approval
of Services for students with Disabilities
STAC-5 Forms:
- STAC-5
-
Request for Commissioner's Approval of Reimbursement for
Evaluations.
Please note: This form has been optimized as a fillable form with additional accessibility support for visitors with visual impairments. It is a large file and may take a little while to download. After the form finishes downloading, we recommend saving a local copy to your computer for future use.
Aide/Nurse/Interpreter Forms:
- Preschool Student-Specific Nurses and Interpreters
-
Preschool Request for Reimbursement for All Student-Specific Nurses and All Student-Specific Interpreters
(See list of excluded preschool providers) - School Age Student-Specific Aides, Nurses, and Interpreters
-
School Age Request for Reimbursement for All Out-of-State Student-Specific Education Aides,
All Student-Specific Nurses, All Student-Specific Interpreters, and All Student-Specific Maintenance Aides
(See list of excluded school age providers)
NOTE: Maintenance aides may be requested for CSE-placed students in either an eligible in-state or out-of-state residential facility, excluding Children's Residential Project (CRP) Programs. - Aide Percentage Calculation Worksheet
Eligibility Forms:
- OPWDD STAC-200
-
Notice of Other State Agency (OPWDD) Placement of Children
with Handicapping Conditions.
- OMH STAC-200
-
Notice of Other State Agency Placement
of Children with Handicapping Conditions
- OCFS LDSS 3424 - School District Notification Of Financial Responsibility for Educationally Handicapped Foster Child Placed in a Child Care Institution
- STAC-202 - (DSS) Designation of School District of Attendance for Children in Temporary Housing:
The STAC-202 form indicates that a student has been designated as homeless, and specifies the name of the district the student will be attending. It is also used by local districts to request reimbursement from NYSED for the costs of education a temporarily housed student who moves into the district from another school district in New York State.
School Age Summer Forms:
- Summer Transportation Cost Exceeding $6,500 - Summer Transportation Costs Exceeding $6,500+
- Summer Related Services Exceeding 120 Half-Hour Units - 4408 Summer 9015 Programs
Nonresident Parentally-placed Nonpublic School Students:
- Memo - Addition of Section 177.2 of the Regulations of the
Commissioner of Education Relating to Disputes of Reimbursement
Claims for Special Education Services Provided to Nonresident
Parentally-Placed Nonpublic School Students with Disabilities
- District Application for Administrative Review of a
Claim for Payment
- Submission of Claim to NYSED - No Parent Consent to Share Special Education
Information with District of Residence
Public High Cost Calculation Worksheets:
Use these PDF calculation versions of the Public High Cost Worksheets to document updated costs for claims that were previously verified and locked. These versions of the forms can also be used to calculate estimated costs prior to entry on the STAC Online (EFRT) System.
- DCPUB
- High Cost Worksheet for In-District/BOCES Placements
- DCPOD
- High Cost Worksheet for "Other District" Placements
Please note:
Enter the value from Line 4 of the PUB State Aid Output Report in the Public Excess Cost Aid Ratio box.
Enter the value from Line 5 of the PUB State Aid Output Report in the District Threshold box.
The correct State Aid Output Report will be one year more recent than the enrollment year.
Update Child Information:
Forms Not Requiring Personally Identifiable Student Information
Scan and email completed forms to OMSSTAC@nysed.gov.
STAC Online System (EFRT) Forms:
- Request for Addition(s) to Drop Down Menu Form
- Request to Change Program Dates Form
- Notice of Modified Instructional Hours for School Age Approved 9010 Summer 4408 Program
- Request Access to the STAC Online System:
- Employees
of Districts, Municipalities and SED-Approved Providers
- Consultants
under written contract with Districts, Municipalities and SED Approved Providers
- Employees
- Authorization Form for Access to the SED File Transfer Manager (FTM)