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.