Non-Educational Community-Based Support Services
Application for Funding
Education Service Center Region 20
School Year 2015-2016
Authority for Data Collection: TEC §29.013
Planned Use of Data: To determine the cost of Non-Educational Community-Based Support Services for students with
disabilities and ensure that this request for service is in accordance with state laws and rules.
Instructions:
Enter an “X” in the box to indicate whether the request for Non-Ed funds is new (application submitted first time for this student),
continuing (application submitted for this student to continue Non-Ed services from previous year), or amendment/cost revision
(to revise activity or cost of an approved 2015-2016 application).
Complete each item in the application. Do not leave any items blank.
The term “LEA” throughout this application denotes an independent school district or open-enrollment charter school.
The term “Non-Ed” denotes Non-Educational Community-Based Support Services.
☐ New
☐ Continuing
☐ Amendment/Cost Revision
Dates of Services: Beginning: 9/1/2015 (OR,
if later than 9/1/2015)
Ending: 8/31/2016
ESC Stamp-in Date
Student’s Name:
Student’s Primary Disability:
Student’s Gender:
☐M ☐ F
Student’s Age (as of 9/01 of current fiscal year):
Student’s Ethnicity:
Student’s Primary Language:
Name of ISD or Charter School:
County-District Number (CDN):
Student’s Home Campus:
Campus Where Student is Attending:
2015-2016 Non-Ed Funds Application
Education Service Center, Region 20
Page 1 of 9
Parent/Guardian Information
Typed Name of Parent/Guardian:
Telephone:
☐ Parent(s) or Guardian(s) is in agreement with this application.
Contact Information for Person Completing this Application
Typed Name of Person at LEA Completing Application:
Telephone:
Title of Person at LEA Completing Application:
E-mail Address of Person at LEA Completing Application:
LEA Special Education Director Information
Typed Name of Special Education Director for LEA:
Telephone:
E-mail Address of Special Education Director for LEA:
LEA Contact for Billing/Invoices for this Program
Typed Name of Business/Finance Contact for LEA:
Telephone:
Fax:
E-mail Address of Business/Finance Contact for LEA:
Contact Information for Person of MRA, MHA, or CRCG
Typed Name of Mental Retardation Authority (MRA) or Mental Health
Authority (MHA), or Community Resource Coordination Group (CRCG)
Contact Person:
Check One:
☐MRA
Telephone:
☐MHA
☐CRCG
Title of MRA, MHA, or CRCG Contact Person:
2015-2016 Non-Ed Funds Application
Education Service Center, Region 20
Page 2 of 9
NOTE: Non-Ed services shall not be provided to a student with disabilities who is in need of residential
placement for non-educational reasons.
Non-Ed funds may not be used if the services could be provided with education funds.
Non-Ed services for families with a child with Autism are limited to respite care and/or attendant care.
In-home training of viable alternatives and parent training that support the student’s individualized education
program (IEP) must be paid with educational funds as required by TAC §89.1055(e) and are not allowable with
Non-Ed funds.
Non-Ed services are not intended to be intensive or long-term but rather, periodic and short-term.
The following questions must be completed by LEA staff to provide adequate information for ESC staff to ensure
that necessary criteria are met before this application is approved. Be specific when providing answers.
1.
Current Status. This student is:
☐At risk for residential placement, primarily for educational reasons.
OR
☐Returning from residential placement, placed primarily for educational reasons.
2.
Briefly describe your impressions of the student:
3.
Briefly describe the student’s strengths:
2015-2016 Non-Ed Funds Application
Education Service Center, Region 20
Page 3 of 9
4.
Describe the student’s behavior(s) that contribute to the need for Non-Ed services. List specific
behaviors observed at home and at school, including frequency (how often the behavior occurs; i.e. daily,
weekly, monthly, yearly), duration (how long the behavior lasts), and intensity (severity of the behavior when
it occurs; i.e. mild, moderate, severe):
Behavior(s) Contributing to Need for Non-Ed Services
5.
Frequency
(How often
behavior
occurs)
Duration
(How long
behavior
lasts)
Intensity
(Severity
of
behavior)
List academic and behavior intervention(s) implemented by the LEA regarding behaviors described in
Question 4 and include the instructional setting and teacher/student ratio:
Academic and Behavior Interventions
provided for behaviors
listed in Question 4
2015-2016 Non-Ed Funds Application
Education Service Center, Region 20
Instructional Setting
Teacher/
Student
Ratio
Page 4 of 9
6.
For continuing applications, describe the previous use of and benefit from Non-Ed funds.
If this is a new application, please indicate N/A.
☐N/A (if New Application)
OR
☐Previous Use/Benefit from Non-Ed Funds, if applicable.
If this option is chosen, please provide description:
7.
Describe MRA/MHA or any other agency involvement that has focused on maintaining the student in the
home and in the local school program:
8. List previous out-of-home placements and provide the reason and duration for each placement.
If not applicable, please indicate N/A.
☐N/A (if no previous out-of-home placements)
OR
☐Previous out-of-home placement, if applicable. Please describe below:
Previous out-of-home
placements
2015-2016 Non-Ed Funds Application
Reason
for previous placement
Education Service Center, Region 20
Duration
of previous placement
Page 5 of 9
9. Describe anticipated future funding needs and include other sources of funds for services.
If not applicable, please indicate N/A.
☐N/A (if no anticipated future funding needs)
OR
☐Anticipated future funding needs, if applicable. Please describe below:
Other sources of funds for
anticipated future services
Anticipated future funding needs
10. Briefly describe pertinent academic and behavioral information for each year. This information must be
based on a student’s individualized educational program (IEP), report card, or any other progress reports.
If a continuing application, must indicate at least two years, including the current year.
11.
If application is submitted prior to the beginning of the 2015-2016 school year, indicate information from
2014-2015 and 2013-2014.
12.
If a new application, must indicate at least the current year.
If application is submitted prior to the beginning of the 2015-2016 school year, indicate information from
2014-2015.
School Year
Name of Facility or LEA
Academic Information
Behavioral Information
2015-2016,
if data available
2014-2015
2013-2014
2015-2016 Non-Ed Funds Application
Education Service Center, Region 20
Page 6 of 9
11. Non-Ed Services. It is required that a planning meeting be held to discuss options for Non-Ed services and to
determine whether or not these services are needed. Persons attending and participating in this meeting
should include LEA staff knowledgeable about the student, and the parent(s), and representative(s) from the
MRA, MHA, or CRCG, or other service providers. The student’s admission, review, and dismissal (ARD)
committee may not serve as this planning group and should not make the decision regarding services.
Indicate need(s) for which funds are being requested. For each need, indicate a description of requested
service(s) and proposed service provider(s).
NEED(S)
Describe each need for which Non-Ed funds are being requested:
Indicate each need for which funds are
being requested. Each need should be
directly related to the behavior described in
Question 4.
SERVICE(S)
Service(s) must agree with the cost analysis
(see Question 12) indicating the service to
meet each need for which funds are being
requested.
DESCRIPTION OF SERVICE(S)
(No data entry required in this field.)
Requested Service(s) are indicated on Question 12.
Describe how the requested service(s) are non-educational:
Describe how each requested service in
Question 12 is non-educational and/or
different from educational services.
PROPOSED
SERVICE PROVIDER(S)
Indicate whether the provider is the local
MRA/MHA, LEA, or other provider. Indicate
type of position for each provider.
Indicate Type of Service Provider(s) and Type of Position(s) associated
with the provider:
(May select more than one)
☐MRA/MHA
Position(s):
☐LEA
Position(s):
☐Other Service Provider(s)
Position(s):
2015-2016 Non-Ed Funds Application
Education Service Center, Region 20
Page 7 of 9
12. Non-Ed Cost.
Non-ed services costs must reflect the information provided in Question 11. Indicate the type of service to be
provided, frequency type, rate, and how many times the service will be provided during the approval period.
Non-Ed
Services Requested
(Must be a service from the
**Service Type** chart below)
Frequency Type:
Indicate either Daily, Hourly,
Weekly, Monthly, or
Annually
Rate
(dollar amount)
corresponding to
Frequency Type
(Example: If Frequency
Type is Hourly, indicate
hourly rate)
Number of Times
Service Will Be
Provided
(corresponding to
Frequency Type)
Total Cost
(Rate x Number of
Times Service
Provided)
(Example: If Frequency
Type is Hourly, indicate how
many hours during the year
the service will be provided.)
1.
$
$
2.
$
$
3.
$
$
4.
$
$
5.
$
$
Total for all services
requested
$
**Service Type**
Refer to Frequently Asked Questions document for description of services
*Note: Respite Care and Attendant Care are the only services allowable
with Non-Ed funds for students with Autism.
1. Respite Care*
2. Attendant Care*
3. Psychiatric/Psychological
Consultation
4. Management of Leisure Time
5. Socialization Training
6. Individual Support


7.
8.
9.
10.
11.
12.
Family Support
Family Dynamics Training
Generalization Training
Peer Support Group
Parent Support Group
Transportation to access
approved Non-Ed services
Revenue and expenditure amounts will be kept in accordance with the TEA Financial Accounting System Resource Guide.
Fund Number 392 shall be used for Non-Educational Community-Based Support Services.
ASSURANCES
2015-2016 Non-Ed Funds Application
Education Service Center, Region 20
Page 8 of 9
The LEA applying for the Non-Educational Community-Based Support Services assures that it will:
1. Ensure that an interagency group of people knowledgeable about the student and the parents have agreed upon
the services to be provided.
2. Develop a contract with the service provider approved by the LEA, as applicable, for approved Non-Ed services.
3. Verify services rendered prior to payment to the service provider.
4. Ensure that payments from Non-Ed funds will only be paid to the service provider approved by the LEA and will not
be paid directly to the family.
5. Ensure that services being requested are not intended to be intensive or long-term, but rather, periodic and shortterm.
6. Ensure that Non-Ed funds are used for non-educational support services.
7. Ensure that Non-Ed funds are used only for eligible students with disabilities who would remain or would have to
be placed in residential facilities primarily for educational reasons without the provision of Non-Ed services.
If the student’s district of residence or charter school is a member of a special education shared services arrangement
(SSA), the fiscal agent’s signature assures that the SSA member accepts and agrees with these assurances.
CERTIFICATION
1. We certify that the information in this document is true and correct and that these statements of assurance are
accepted.
2. We certify that the provision of services does not supersede or limit the responsibility of other agencies to provide
or pay for costs of Non-Educational Community-Based Support Services.
3. We certify that parents, CRCG and/or MRA/MHA staff, and local education agency (LEA) staff were involved in the
development of this application.
4. We certify that any ensuing program and activity will be conducted in accordance with federal and state laws and
regulations. It is understood by the applicant that this application constitutes an offer and will form a binding
agreement.
5. We certify that the CRCG Chairperson or designee recommended/approved the service(s) identified in Question
12 of the application.
REQUIRED SIGNATURE OF CRCG CHAIRPERSON OR DESIGNEE:
Typed Name of CRCG Chairperson or
Telephone:
Date:
designee:
Signature:
Title of Person Named Above:
REQUIRED SIGNATURE OF SUPERINTENDENT OR DESIGNEE:
(If anyone other than the Superintendent signs this application, the appropriate authorization must be attached)
Typed Name of LEA’s (or SSA Fiscal
Agent’s) Superintendent or designee:
Telephone:
Date:
Signature:
Title of Person Named Above:
2015-2016 Non-Ed Funds Application
Education Service Center, Region 20
Page 9 of 9