INSTRUCTIONS TO LEA FOR COMPLETING (sample attached) The Individual Service Agreement (ISA) 08/09 LEA Master Contract LEA must complete and submit the ISA to the NPS or NPA before commencement of services. Do not submit ISA’s to NPS or NPA in blank. Complete Name of Local Education Agency (your District) and all student information. A. Basic Education Program Enter the number of regular and extended school days student will attend in boxes. For Partial Day Students enter the number regular and extended school days student will attend, rate per minute is NPS Daily Tuition rate divided by NPS Instructional minutes, enter total number of minutes per day student will attend per IEP. B. Individual Pupil Specifications will need completion. 2. Indicate pupil/student ratio for related services 5. If clarification is needed, or not clear in IEP, indicate here. 6. Other Provisions -Examples of items to put here include:
Partial day student schedule and payment for such if necessary. Special location or arrangements for related services. Special medical treatment or behavior intervention not clearly indicated in IEP. Other pertinent service the NPS/A must perform for student. Any pertinent LEA board adopted policy for serving students, which might apply to this student.
C. DIS and Related Services
Indicate the number of minutes for each service Enter the frequency of the service by times per week or month Enter service WK (week), Month or Year Enter the start date of DIS service Enter the estimated hours or number of sessions until next IEP Enter the Total Basic Education Costs from Page 1, Item A in the field for Maximum Total Basic Education Cost Page 2, Item A. Enter the Total Instructional Days from Page 1, Item D in the field for Instructional Days Page 2, Item D
Check the figures automatically converted. Complete Local Education Agency (your district) information fields Sign and submit to NPS/A for signature prior to services starting. The NPS/A has the right to refuse the student services until such time the ISA is submitted by the LEA.
EXHIBIT A
08/09 updated 4/23/08
SAMPLE
ISA Directions and Sample
INDIVIDUAL SERVICE AGREEMENT UNDER THE 2008/2009 MASTER CONTRACT FOR NONPUBLIC, NONSECTARIAN SCHOOL/AGENCY SERVICES NAME OF LOCAL EDUCATION AGENCY: Any School District name NAME OF NONPUBLIC SCHOOL/AGENCY: PUPIL’S NAME:
Any Nonpublic School name
Jones Suzi SEX: ( ) M ( X) F (Last) (First) (Middle) PUPIL’s I.D./S.S. #: 555-55-5555 BIRTHDATE: 3/8/87 GRADE: unraded RESIDENTIAL SETTING: (X) HOME ( ) FOSTER ( ) LCI LCI PHONE # __________________ PUPIL’S ADDRESS: 1234 Mendocino Ave, Santa Rosa, CA 95401 PARENT/GUARDIAN’S NAME: Sue Jones PHONE: (707)546-1234 n/a (Residence) (Business) NON-EDUCATIONAL PLACING AGENCY: (If applicable) ________________________________________ All terms and conditions of the current LEA Master Contract for Nonpublic, Nonsectarian School/Agency Service (NPS/NPA), hereinafter referred to as the “Contract,” are incorporated herein by this reference. Contractor will implement the pupil’s Individualized Education Program (IEP) in accordance with this Individual Service Agreement and the Contract. Invoices shall be submitted based on actual service provided and attendance standards in the Contract. A. BASIC EDUCATION PROGRAM (Applies to Nonpublic schools only)
Contractor shall enroll pupil in its Basic Education Program commencing on 7/1/2007 and ending on 6/30/2008, unless earlier terminated by notice from LEA upon pupil’s change of residence, change of placement or termination of the Master Contract. Number of Regular = Total Regular School Year Basic $17,239.00 $172.39 100 Per School Days Diem Education Costs (Adjusted annually) Partial Day Student Number of Regular School Days Number of ESY Days
80 15
Per Minute Per Diem
$.54 $172.39
120 = Total ESY Basic Education Costs (Adjusted annually)
= Partial Day Student Total Regular School Year Basic Education Costs (Adjusted Annually)
$5,184.00 $2,585.85
= Partial Day Student Total ESY Partial Day Student Per $.54 15 Basic Education Costs Number of ESY Minute 120 $972.00 (Adjusted Annually) Days Total Instructional Total Basic Education Costs -Adjusted annually $25,980.85 10 Days (Item-D page 2) (Item -A on page 2) B. INDIVIDUAL PUPIL SPECIFICATIONS (Complete # 2 and #5 or reference IEP) 1. The pupil’s teacher/service provider will hold the appropriate credential/license to provide such service as issued by California Commission on Teacher Credentialing or the appropriate California Licensing Agency. 2. The class size for the pupil will not exceed 12 and/or the therapist/pupil ratio will not exceed __1:1___. 3. The length and content of the Basic Education Program will be consistent with the Contract unless otherwise specified. 4. Contractor shall provide authorized services in accordance with the pupil’s IEP and this Individual Service Agreement. 5. Method for complying with statewide standardized assessment requirements: Parent Exemption, letter from parent dated 3/1/08 in cum ___________________________ _____________________________________________________________________________________ 6. Other Provisions: N/A ______________________________________________________________ _____________________________________________________________________________________
C.
DESIGNATED INSTRUCTION AND SERVICES/RELATED SERVICES: ESTIMATE
ISA Directions and Sample
08/09 updated 4/23/08
Pupil’s Name: Suzi Jones
MINUTE
S
SERVICE PROVIDED
FREQUENCY (TIMES
PERWEEK/ MONTH/
COST PER HOUR AS SET
FORTH IN MASTER CONTRACT
ESTIMATED SESSIONS
UNTIL NEXT
WK/
MONTH/
START DATE
IEP * OPTIONAL
YEAR
N/ A N/ A
YEAR)
ESTIMATED TOTAL * OPTIONAL (EQUALS COST PER HOUR TIMES (X) ESTIMATED SESSIONS, TIMES (X) HOURS PER SESSION)
1. Adapted PE 2. 1:1 Assistant (Temporary) 3.Behavior Intervention 4.Counseling 5. O.T. 6. Speech/Lang 7. H/Nursing 8. Transp. 9. O. M. 10.Adapted Vision 11. na
N/ A
N/ A
$94.72 $19.68 $92.90 $76.51 $87.45 $87.45 $98.38 $35.88
day
N/a 211 N/a 42 12 84 N/a a 211 N/a N/a
N/a $16,609.92 N/a $3,213.42 $1,049.40 $7,345.80 N/a $7,570.68 N/a N/a
240 (4 HRS)
N/ A
5
WK
7/1/07
N/ A
N/ A
N/ A
60 30 60
N/ A
1 1 2
N/ A
WK MONTH WK
N/ A
7/1/07 7/1/07 7/1/07
N/ A
5
N/ A N/ A N/ A N/ A
WK
N/ A N/ A
7/1/07
N/ A N/ A
$94.72 $98.38 N/a (C)
NA
NA
NA
NA
*MAXIMUM DIS AND RELATED SERVICES COST ESTIMATE
*MAXIMUM TOTAL BASIC EDUCATION COST (A) ESTIMATE *Maximum Total Basic Education and DIS/Related Services Cost Estimate INSTRUCTIONAL ESTIMATED PER DIEM – BASIC DAYS - ITEM D EDUCATION AND DIS/RELATED SERVICES 210
DIVIDED BY INSTRUCTIONAL DAYS FROM PAGE 1
N/a N/a Above Estimated $35,789.22 Totals Item A from $25,980.85
page 1
(A + C) (A + C
divided by
$61,770.07 $294.14
D)
The parties hereto agree to comply with the terms of the Master Contract and hereby execute this Individual Service Agreement by and through their duly authorized agents or representatives.
Contractor Any Nonpublic School
Any School District name
(Authorized Signature)
(Date)
Any Nonpublic School 1234 Street Way Santa Rosa, Ca 95401 (707)555-5555 Local Educational Agency
08/09 updated 4/23/08
(Authorized Signature) (Date) Name of Special Ed Director (Type or Print Name) 1111 Street Way, Santa Rosa, CA 95401 (Mailing Address) (telephone number) (707)111-1111
ISA Directions and Sample