New York State Office of Children and Family Services



NEW YORK STATEOFFICE OF CHILDREN AND FAMILY SERVICESResidential Placement Checklist for School Districts Regulation 4 INTERSTATE COMPACT ON THE PLACEMENT OF CHILDREN (ICPC)This checklist is for use by school district personnel when submitting out-of-state placement requests under ICPC Regulation 4: Residential Placement. If you have questions, contact NY ICPC at ocfs.sm.NYSICPC@ocfs. or 518-474-9406. Mailing Address: NY ICPC, 52 Washington Street, Room 331 North, Rensselaer, NY 12144. For more information, see ocfs.programs/adopt/ICPC/. STEP ONE—INITIAL REFERRAL: Send your complete packets to the mailing address or email address listed above. NY ICPC will review your packet and submit it to the Receiving State for a placement decision. FORMCHECKBOX FORM ICPC 100A: Complete ALL fields.SECTION I IDENTIFYING DATA: name of agency or person responsible for planning for child: Enter Parent/Guardian informationname of agency or person financially responsible for child: Enter School District informationSECTION II PLACEMENT INFORMATION: Must reflect full name and address of placement facility.type of care requested: Select residential treatment center or institutional care-article-IV, adjudicated delinquent current legal status of child: Select Parent Relative Custody/Guardianship SECTION III SERVICES REQUESTED: supervisory services: Select Another Agency has agreed to supervise signature of sending agency or person: Signed and dated by the Authorized School Official AND at least one (1) of the Custodial Parents/Guardians. Dates and signatures on the same line. FORMCHECKBOX COVER LETTER: A current letter from the school district, signed and dated, to include: contact information for the school district contact person; name and date of birth of child, and name of the proposed placement facility;reason(s) for child’s out-of-state placement and services needed during placement;name of individual(s) and/or agency responsible for medical, boarding, and educational costs; andname of individual(s) and/or agency responsible for returning the child to the home state in the event of a placement disruption. FORMCHECKBOX FACILITY ACCEPTANCE LETTER: A current letter, signed and dated by an authorized representative of the proposed placement facility. FORMCHECKBOX EDUCATIONAL & PSYCHOSOCIAL RECORDS: IEP and/or Psychological/Psychiatric report that describes the child’s current functioning and need for residential placement. FORMCHECKBOX CHILD’S SOCIAL SECURITY CARD & BIRTH CERTIFICATE: If documents are unavailable at the time of ICPC referral, please state this in the cover letter and forward copies to NY ICPC once available. STEP TWO—PLACEMENT DECISION: The Receiving State will return the completed ICPC 100A with their placement decision. If placement is approved, you will submit a signed and dated ICPC 100B to NY ICPC. This alerts the Receiving State of the initial placement or that you will not use the approved resource for placement. FORMCHECKBOX FORM ICPC 100B — Complete sections I, II, and IV to PLACE the child. Complete sections I, III, and IV if you intend to close the ICPC without placing the child.STEP THREE—COMPACT TERMINATION: Provide Form ICPC 100B to close the ICPC case upon treatment completion or other applicable placement termination. This alerts the Receiving State that the child has returned to the Sending State. FORMCHECKBOX FORM ICPC 100B — Complete sections I, III, and IV. Submit the form to NY ICPC. ................
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