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					                             Adult and Career Education
                                                                       SECO NDARY CAREER AND TECH NICAL EDUCATIO N TRANSITIO N
                               1500 Highway 36 West                                                                                                                               ED-01445-14
                             Roseville, MN 55113-4266                       DISAB LED CO NTRACTED SERVICES - REQUEST FO R APPRO VAL

USE ONE REPORT FOR EACH AGENCY/DISTRICT CONTRACTED BY YOUR DISTRICT/CENTER                                                                                               PRE-APPROVAL
                                                                                                                 THIS REPORT IS SUBMITTED FOR (check one)
              READ INSTRUCTIONS ON REVERSE SIDE                                                                                                                          FINAL APPROVAL

                                                               IDENTIFICATION AND GENERAL INFORMATION
                                                                                                       RETURN TO (If different than REQUEST FROM)
REQUEST FROM (Please Print):
                                                                                                                     (Please Print):
District or Center Name                                               Type and Number                Name

Address                                    City                     State       Zip Code             Address                          City                    State            Zip Code

Program Name as reported on EDRS (Electronic Data Reporting System)                                  Program O.E. Code Number

Fiscal Year      Name of Person Completing this Form                                                 Title                             Telephone Number              Fax Number
                                                                                                                                       (   )    -                    (    )     -
Name of Contracting Agency                                              Contracting Agency Address                                                If Contracting Agency is a school district,
                                                                                                                                                  provide district number:

                               CAREER AND TECHNICAL                          EDUCATION CONTRACTED SERVICES INFORMATION
                                                                                                          USAGE TYPE         CLOCK HOURS STUDENT IS
                                                            GRADE     BRIEF DESCRIPTION OF CONTRACTED                                                                     EXPENDITURES
           STUDENT NUMBER *                                                                           (See back for details)         SERVED
                                                            LEVEL            SERVICES PROVIDED**
                                                                                                      390     393      394   ESTIMATED     ACTUAL                     ESTIMATED       ACTUAL




* MARSS Student State Reporting Number                **A copy of the contract MUST be attached with each request for pre-approval.


        APPLICATION SIGNATURE                                                                                STATE APPROVAL SIGNATURES
I hereby verify that the above information is true and
correct to the best of my belief and knowledge. A copy of
the contract for services is attached.                              STATE PRE-APPROVAL
                                                                        SIGNATURE                    _____________________________________________________              ___________________
   __________________________________________                                                                            Program Specialist                                    Date
       Signature – Career & Technical Education
                Director/Superintendent

                                                                    STATE FINAL APPROVAL
          ______________________________                                 SIGNATURE
                                                                                                     ____________________________________________________               ____________________
                       Date                                                                                             Program Specialist                                     Date
             DIRECTIONS FOR SUBMITTING CONTRACTED SERVICES REPORT
GENERAL INFORMATION AND INSTRUCTIONS: Complete this report when funding is being requested for contracted services
associated with a career and technical education (CTE) program for students with disabilities. This report plus the contract must be submitted
for PRE-APPROVAL prior to the services occurring. A signed copy will be returned to the LEA. Use the signed copy to submit actual
expenditures and actual clock hours at year-end (August 15) for FINAL APPROVAL. The LEA is not eligible for funding if pre-
approval has not been granted.
SCHOOL DISTRICT IDENTIFICATION:
District Type: Enter the number indicating the type of district for which you are claiming transition - disabled aids for programs for students
with disabilities.
01    -   Independent School Districts                 52 - Special Education Cooperatives
03    -   Special                                      53 - Combination Career & Technical Education / Special Education
06    -   Intermediate School Districts                     Cooperative Centers
51    -   Vocational Cooperative Centers               61 - Education Districts
                                                       83 - Service Cooperatives
District Number: Enter the four-digit school district number.
Fiscal Year: Enter the Fiscal Year to which the report data is applicable.
Name and Address of Contracting Agency: Enter the name and address of the agency or school district with whom you are contracting. If
you are contracting with a school district, the school district number must be provided.
Student Number: Enter the 13-digit MARSS Student State Reporting Number.
Grade Level: Enter the grade level in which the student was enrolled when the service was provided.
Contracted Services: Indicate the contracted services provided by a public or private agency other than a Minnesota school district or
cooperative center for secondary career and technical education programs for students with disabilities. Allowable contracted career and
technical education programs include training and services that prepare students with disabilities for:
1. Competitive Employment (e.g. employment above minimum wage without long-term support), or
2. Supportive Employment (e.g. paid employment in the community where a learner will require ongoing support to be employed).
Contracted services that do not qualify include training and services that prepare students for center-based or sheltered employment (e.g. paid
employment on the premises of a community rehabilitation program).
Contracted career and technical education training and services must be specified in the student’s individual education plan (IEP).
Usage Type:
390        Payments for Educational Purposes to Other Minnesota School Districts
           Expenditures for a contract approved by the commissioner with another Minnesota school district or cooperative center for
           vocational evaluation services for children with a disability that are not yet enrolled in grade 12.
393        Transition Programs for Children with a Disability
           Expenditures for transition-disabled programs for children with disabilities provided by a contract approved by the commissioner with
           public, private, or voluntary agencies other than a Minnesota school district or cooperative center, in the place of programs
           provided by the district (during regular school hours).
394        Payments for Educational Purposes to Other Agencies (Nonschool Districts)
           Expenditures for transition-disabled programs for children with disabilities provided by a contract approved by the commissioner with
           public, private, or voluntary agencies other than a Minnesota school district or cooperative center, that are supplementary to a full
           educational program provided by the district (outside regular school hours).
Clock Hours: Enter the total clock hours the student is provided with the service(s). Enter by student line item an estimate at the time of
preapproval, and enter the actual clock hours at the year end.
Expenditure: Enter by student line item the Estimated expenditures for contracted services pre-approval and the actual expenditures on the
final approval.
Request for Approval: Contracts must be attached to each Request for Approval.
Invoices: The district must submit copies of paid invoices with the final claim for reimbursement of expenditures by August 15.

				
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