NPS/A Out of State Placement - Data Collecting & Reporting ...
Reporting of Out-of-State Nonpublic, Nonsectarian School/Agency Placement
California Education Code 56365(f)
This report is required to be submitted within 15 days of the placement decision to:
Interagency-Nonpublic Schools/Agencies Unit
Special Education Division
California Department of Education
1430 N Street, Suite 2401
Sacramento, CA 95814
Phone 916-327-0141 FAX: 916-327-5233
|1 |Placing Agency Information |
| |Placing Agency: |
| |Address: |
| |City: |State: |ZIP Code: |
| |Contact Person : |Telephone: |
| |Signature: |
|2. |Student Information |
| |Student ID# : |Date of Birth: |
|4.. |Nonpublic School/Agency (NPS/A) Information |
| |NPS/A Name: |
| |Is the NPS/A currently California-certified? Yes No (Requires Waiver) |
| |Address: |
| |City: |State: |ZIP Code: |
| |Contact Person: |Telephone: |
| |Date of Placement: |For School Year(s): |
| |Anticipated Date of Return to a California Placement: |
|5. |Out-of-State Pupil Placement and Costs |
| |Note: Continue description in Item 6. Use additional sheets, if necessary. |
| |Check appropriate box |
| | |Full Day NPS Placement |Contract Cost: |
| | |Partial Day NPS Placement |Contract Cost: |
| | |Residential NPS Placement |Contract Cost: |
| | |Full Day NPA Placement |Contract Cost: |
| | |Partial Day NPA Placement |Contract Cost: |
|6. |Describe Out-of-State Pupil Placement and Costs |
| | |
|7. |Related Services. List and identify cost of related service(s). Use additional sheets, if necessary. |
| | |
|8. |Describe the efforts to locate an appropriate public school, NPS/A, or a combination, thereof, within the State of California. |
| | |
California Department of Education
Updated May 10, 2017
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