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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