Evaluation Form Instructions
REVISED 06/30/2020
INSTRUCTIONS FOR COMPLETION OF THE
STAC-5 EVALUATION FORM
(Request for Commissioner’s Approval of Reimbursement for the Cost of Evaluations Pursuant to Section 4410 of the Education Law)
| DATA ITEM | DESCRIPTION |
|---|---|
| STAC-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. |
| Last Name, First Name, Middle Initial | Be accurate and consistent. Use of nicknames can lead to duplicate ID numbers. If a child has been adopted, submit a Child Information Change Form so that the child’s name can be changed on the system. |
| Date of Birth (mm/dd/yy) | Indicate the child’s birth date. Submit a Child Information Change Form to correct a child's date of birth. |
| Student Identification Number | If the CPSE district utilizes its own student identification number, enter it here. Otherwise, leave blank. |
| Gender | Indicate the gender of the child by checking the appropriate box. |
| 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 If, for any reason, a student is withdrawn from the CPSE process before the CPSE makes a determination regarding the existence of an educational disability, the district should check the “Non-Disabled”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. |
| Racial Ethnic Category of Student | Indicate whether the student is Hispanic or Latino. If the student is not of Hispanic origin, select the racial/ethnic category by checking the appropriate category. |
| School District with CPSE Responsibility | Enter the name and SED (BEDS) Code of the school district that has CPSE responsibility for this student. |
| 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. |
| County at time of Placement in Foster Care | 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. |
| Approved Evaluator | Enter the name of the agency that conducted the evaluation. |
| Evaluation Component, Month/Year, Check if Bilingual | 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. |
| Cost of translation/transmittal of evaluation documentation or summary report for monolingual evaluations only. | 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. |
| Person Completing This Form | Enter the name, title, phone number, and email address of the person who completed this form. This will allow the STAC Unit staff to resolve any problems or questions about the STAC-5 in the most timely manner. |
| Certification of Evaluation | The CPSE Chairperson must complete this field. |
| Municipality | All requests submitted to SED must be authorized by the Municipality Representative. |
Last Updated:
June 2, 2023