869-4 Table 3 Part B , Individuals with Disabilities Education

Page 11 of 11

TABLE 3

PART B, INDIVIDUALS WITH DISABILITIES EDUCATION ACT

IMPLEMENTATION OF FAPE REQUIREMENTS

Child Count Date for 2006

Paperwork Burden Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 1820-0517. The time required to complete this information collection is estimated to average 28 hours per SEA and 27 hours per LEA response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Education, Washington, D.C. 20202. If you have comments or concerns regarding the status of your individual submission of this form, write directly to: Office of Special Education Programs, U.S. Department of Education, 400 Maryland Avenue, SW, Washington, D.C. 20202.

Authorization: P.L. 108-446, Section 618 (a)(1)(A)(ii), Section 618 (a)(1)(A)(iii), and Section 618 (a)(3); 34 CFR §§300.640, 300.641, 300.642(b), 300.644, 300.645

Due Date: February 1, 2007

Sampling Allowed: Section A – Yes

Section B – Yes

Section C – No

Section D – Yes

Section E – Yes

Section F – Yes

Section G – No

Section H – Yes

Section I – Yes

Send Form to: Alexa Posny, Director

Office of Special Education Programs

Part B Data Reports

Program Support Services Group

Mail stop 2600

550 12th Street, S.W.

Washington, D.C. 20202

Attn: Cheryl Broady

General Instructions

Provide a count of children ages 3-5 served under the IDEA, Part B program, according to their educational environments. Report data by discrete age year, disability category,¹ race/ethnicity, gender and Limited English Proficiency (LEP) status.

Report a count of all children with disabilities ages 6-21 served under the IDEA, Part B program, according to their educational environments. Report data by age category and disability category, race/ethnicity, gender, and LEP status.

This table does not require a separate, certified count of children. However, it is intended to reflect the number of the children receiving services, reported by the appropriate environment category, on the date of the child count. The count is to be taken on a state-designated date between October 1, 2006 and December 1, 2006 (inclusive). States must use the same count date each year. States must use the same date for reporting educational environments data that is used in reporting the child count for that year.

Place zeros in categories where cells contain no numeric values. Report (-9) in categories not used by the State.

STATES SHOULD NOT PROVIDE PERCENTAGES IN SECTIONS A THROUGH H, AS THEY WILL BE CALCULATED AFTER THE COUNTS ARE SUBMITTED.

Sampling Guidelines

States may use sampling to obtain these data. When sampling is used, a description of the sampling methodology, including a statement about how the design will yield valid and reliable estimates must be submitted to OSEP for approval. The level of precision of the estimates to be obtained must be specified. States must submit sampling plans to OSEP for approval by September 1 of the reporting school year (that is, the September prior to the October or December child count date).

OSEP will evaluate the validity of the sampling plans using the guidelines below.

1. The sampling framework may include all school districts or a sample of districts. If a State chooses to sample districts, all districts with average daily memberships (ADM) of over 50,000 must be included in the sample. States with fewer than 25 districts with ADMs over 25,000 must include all districts with over 25,000 ADMs. The total number of districts sampled must equal or exceed 100. If the total number of districts in the State is 100 or fewer, data must be collected from all districts.

2. When sampling students, whether for all districts or for a sample of districts, data must be collected separately for each Federal disability category. All students whose domicile is in a district must be eligible for the sample including those students served in cooperatives and/or intermediate units or in residential programs out of the district.

3. A minimum sample of 100 children must be used by all districts, except where the total number in a disability category is less than 100. In such a case, data must be collected for all students in that category.

States that use sampling will provide OSEP with weighted rather than unweighted data. A description of the final sample sizes and the weights used should also be provided at the time the data are provided.

Specific Instructions

Section A: Discrete Age Year of Children with Disabilities Ages 3-5 by Educational Environment

REPORT AN UNDUPLICATED COUNT OF ALL CHILDREN WITH DISABILITIES AGES 3-5 SERVED UNDER IDEA, PART B, BY DISCRETE AGE YEAR AND EDUCATIONAL ENVIRONMENT.

When reporting educational environments for children ages 3 through 5, use the following decision rules to determine which environment to use when reporting each child. Please note that the order of the categories for children with disabilities ages 3-5 does not reflect a continuum from least to most restrictive.

1. The first factor to consider is whether the child is attending a regular early childhood program, as defined below. If so, report the child in row A1, A2, or A3. Report the child in one of these environments even if the child receives special education services in other environments. Refer to the instructions in the section below to determine which of percent of time category is appropriate.

Early childhood program. A program that includes at least 50 percent nondisabled children. Early childhood programs include, but are not limited to:

• Head Start;

• kindergarten;

• reverse mainstream classrooms;

• private preschools;

• preschool classes offered to an eligible pre-kindergarten population by the public school system; and

• group child care.

Attendance at an early childhood program need not be funded by IDEA, Part B funds.

2. If the child does not attend a regular early childhood program or kindergarten, the next factor to consider is whether the child attends a special education program, as defined below. If so, report the child in row B1, B2, or B3 according to the location of the special education program. Report the child in one of these environments even if the child also receives special education at home or in a service provider location.

Special education program. A program that includes less than 50 percent nondisabled children. Special education programs include, but are not limited to, special education and related services provided in:

• special education classrooms in

• regular school buildings;

• trailers or portables outside regular school buildings;

• child care facilities;

• hospital facilities on an outpatient basis;

• other community-based settings;

• separate schools; and

• residential facilities.

3. Home. If the child does not attend a regular early childhood program or a special education program, the next factor to consider is whether the child receives some or all of his/her special education services in the home. If the child receives any of his/her special education services in the home, report the child in row B4.

4. Service provider location. If the child does not receive any special education services in the home, report the child in row B5.

Calculating Time in Regular Early Childhood Programs

When determining whether to report a child in A1, A2, or A3, you must calculate the percentage of time the child spends in a regular early childhood program. The numerator for this calculation is the amount of time per week the child spends in a regular early childhood program. The denominator for this calculation is the total number of hours the child spends in a regular early childhood program PLUS any time the child spent receiving special education and related services outside of a regular early childhood program. The result is multiplied by 100. For example,

• If the child attends a regular early childhood program 6 hours a week and receives special education and related services in a special education program for an additional 4 hours a week, report the child in A2, in the regular early childhood program 40% to 79% of time
  (6 ÷ 10 =.60*100=60%). Include in the denominator any time spent receiving special education in the special education program. This is true even if the child receives little or no special education in the early childhood program.

• If the child attends a regular early childhood program 6 hours a week and receives 1 hour of special education and related services at home and an additional half hour of special education and related services a service provider location, report the child in A1, in the regular early childhood program at least 80% of time (6 ÷ 7.5 = 0.8*100=80%).

• If a child is pulled out of the regular early childhood program to receive special education, this is considered time outside the regular early childhood program. Include this time in the in the denominator but not the numerator of the calculation. For example, if a child attends a regular early childhood program for 6 hours a week, and is pulled out of that environment for 2 hours each week to receive speech instruction, report the child in A2, in the regular early childhood program 40% to 79% of time (4 ÷ 6 = .67*100 = 67%).

The educational environments categories are defined as follows:

Row A1. In the regular early childhood program at least 80% of time.

Unduplicated total who attended an early childhood program and were in the early childhood program for at least 80% of time (see instructions for Calculating Time in Regular Early Childhood Programs).

Row A2. In the regular early childhood program 40% to 79% of time.

Unduplicated total who attended an early childhood program and were in the early childhood program for no more than 79% but no less than 49% of time (see instructions for Calculating Time in Regular Early Childhood Programs).

Row A3. In the regular early childhood program less than 40% of time.

Unduplicated total who attended an early childhood program and were in the early childhood program for less than 40% of time (see instructions for Calculating Time in Regular Early Childhood Programs).

Row B1. Separate class. Unduplicated total who attended a special education program in a class with less than 50% nondisabled children. (Do not include children who also attended a regular early childhood program. These children should be reported in columns A1, A2, or A3.)

Row B2. Separate school. Unduplicated total who received education programs in public or private day schools designed specifically for children with disabilities. (Do not include children who also attended a regular early childhood program. These children should be reported in columns A1, A2, or A3.)

Row B3. Residential facility. Unduplicated total who received education programs in publicly or privately operated residential schools or residential medical facilities on an inpatient basis. (Do not include children who also attended a regular early childhood program. These children should be reported in columns A1, A2, or A3.)

Row B4. Home. Unduplicated total who received special education and related services in the principal residence of the child's family or caregivers, and who did not attend an early childhood program or a special education program provided in a separate class, separate school, or residential facility. Include children who receive special education both at home and in a service provider location. The term caregiver includes babysitters.

Row B5. Service provider location. Unduplicated total who received all of their special education and related services from a service provider, and who did not attend an early childhood program or a special education program provided in a separate class, separate school, or residential facility. For example, speech instruction provided in:

• private clinicians’ offices,

• clinicians’ offices located in school buildings,

• hospital facilities on an outpatient basis, and

• libraries and other public locations.

Do not include children who also received special education at home. Children who received special education both in a service provider location and at home should be reported in the home category.

Section B: Educational Environments of Children with Disabilities Ages 3-5 by Disability

REPORT AN UNDUPLICATED COUNT OF ALL CHILDREN WITH DISABILITIES AGES 3-5 SERVED UNDER IDEA, PART B, BY EDUCATIONAL ENVIRONMENT AND DISABILITY CATEGORY. The categories reported in this section must sum to the total reported in Section A.

Use the environment categories defined in the instructions for Section A.

Section C: Educational Environments of Children with Disabilities Ages 3-5 by Race/Ethnicity

REPORT AN UNDUPLICATED COUNT OF ALL CHILDREN AGES 3-5 WITH DISABILITIES SERVED UNDER IDEA, PART B BY RACE/ETHNICITY AND EDUCATIONAL ENVIRONMENT. THE TOTAL DATA REPORTED ON EACH LINE IN SECTION C MUST EQUAL THE TOTAL DATA REPORTED IN THE CORRESPONDING EDUCATIONAL ENVIRONMENT IN SECTION A AND SECTION B.

In October 1997, OMB issued standards for the collection and aggregration of data on race and ethinicity (see “Revisions to the Standards for the Classification of Federal Data on Race and Ethnicity”).  In that announcement, OMB identified a minimum of five racial categories -- American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or Other Pacific Islander, and White -- and one ethnic category -- Hispanic or Latino.  Additionally, OMB announced that individuals should be allowed to select as many race/ethnicity categories as were applicable.  This data collection allows for the reporting of only one race or ethnicity category per individual and is therefore not in compliance with these standards. OSEPand the Department of Education (ED) are considering changes to the categories used for reporting aggregate data to bring this collection into compliance with OMB’s standards. For the time being, data should be reported using the five racial categories described below. 

The race/ethnicity categories are defined as follows:

American Indian or Alaska Native	A person having origins in any of the original peoples of North and South America (including Central America) and who maintains tribal affiliation or community attachment.
Asian or Other Pacific Islander	A person having origins in any of the original peoples of the Far East, Southeast Asia, the Indian subcontinent, or the Pacific Islands. This includes, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, Vietnam, Hawaii, Guam, and Samoa.
Black (not Hispanic)	A person having origins in any of the Black racial groups of Africa.
Hispanic	A person of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race.
White (not Hispanic)	A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
Total	The unduplicated total across the race/ethnicity designations.

Note that children can only be reported in one race/ethnicity category.

Use the educational environment categories defined in the instructions in Section A to report children with disabilities ages 3-5.

Section D: Gender of Children with Disabilities Ages 3-5 by Educational Environment

REPORT AN UNDUPLICATED COUNT OF ALL CHILDREN WITH DISABILITIES AGES 3-5 SERVED UNDER IDEA, PART B, BY EDUCATIONAL ENVIRONMENT AND GENDER. The categories reported in this section must sum to the total reported in Section A.

Use the environment categories defined in the instructions for Section A.

To reduce data burden, gender data for children ages 3-5 are not collected separately on the child count report. Totals on the educational environments report must equal the total number of children with disabilities ages 3-5 reported on the child count.

Section E: Limited English Proficiency Status of Children with Disabilities Ages 3-5 by Educational Environment

REPORT AN UNDUPLICATED COUNT OF ALL CHILDREN WITH DISABILITIES AGES 3-5 SERVED UNDER IDEA, PART B, BY EDUCATIONAL ENVIRONMENT AND LIMITED ENGLISH PROFIENCY STATUS. The categories reported in this section must sum to the total reported in Section A.

Limited English Proficient. A child who meets the definition of a limited English proficient child under the Elementary and Secondary Education Act, 20 U.S.C. Section 7801(A)(25).

LEP status should reflect the child’s status as of the date of the child count.

Use the environment categories defined in the instructions for Section A.

To reduce data burden, LEP status data for children ages 3-5 are not collected separately on the child count report. Totals on the educational environments report must equal the total number of children with disabilities ages 3-5 reported on the child count.

Section F: Educational Environments and Age Category of Children with Disabilities Ages 6-21 by Disability

REPORT AN UNDUPLICATED COUNT OF ALL CHILDREN WITH DISABILITIES AGES 6-21 SERVED UNDER THE IDEA, PART B PROGRAM, BY AGE CATEGORY AND EDUCATIONAL ENVIRONMENT. THE TOTAL LINE ON EACH TABLE MUST EQUAL THE SUM OF THE DISABILITY CATEGORIES.

All counts should represent the setting in which children with disabilities have been placed for educational services.

To calculate the percentage of time inside the regular classroom, divide the number of hours the youth spends inside the regular classroom by the total number of hours in the school day (including lunch, recess and study periods). The result is multiplied by 100. Time spent outside the regular classroom receiving services unrelated to the youth’s disability (e.g., time receiving LEP services) should be considered time inside the regular classroom.

Educational time spent in age-appropriate community-based settings that include individuals with and without disabilities, such as college campuses or vocational sites, should be counted as time spent inside the regular classroom.

Column A. Inside the regular class 80 percent or more of the day. Unduplicated total who were inside the regular classroom for 80 percent or more of the school day. (These are children who received special education and related services outside the regular classroom for less than 21 percent of the school day.) This may include children with disabilities placed in:

• regular class with special education/related services provided within regular classes;

• regular class with special education/related services provided outside regular classes; or

• regular class with special education services provided in resource rooms.

Column B. Inside regular class no more than 79% of day and no less than 40% percent of the day. Unduplicated total who were inside the regular classroom between 40 and 79% of the day. (These are children who received special education and related services outside the regular classroom for at least 21 percent but no more than 60 percent of the school day.) Do not include children who are reported as receiving education programs in public or private separate school or residential facilities. This may include children placed in:

• resource rooms with special education/related services provided within the resource room; or

• resource rooms with part-time instruction in a regular class.

Column C. Inside regular class less than 40 percent of the day. Unduplicated total who were inside the regular classroom less than 40 percent of the day. (These are children who received special education and related services outside the regular classroom for more than 60 percent of the school day.) Do not include children who are reported as receiving education programs in public or private separate school or residential facilities. This category may include children placed in:

• self-contained special classrooms with part-time instruction in a regular class; or

• self-contained special classrooms with full-time special education instruction on a regular school campus.

Column D. Separate school. Unduplicated total who received education programs in public or private separate day school facilities. This includes children with disabilities receiving special education and related services, at public expense, for greater than 50 percent of the school day in public or private separate schools. This may include children placed in:

• public and private day schools for students with disabilities;

• public and private day schools for students with disabilities for a portion of the school day (greater than 50 percent) and in regular school buildings for the remainder of the school day; or

• public and private residential facilities if the student does not live at the facility.

Column E. Residential facility. Unduplicated total who received education programs and lived in public or private residential facilities during the school week. This includes children with disabilities receiving special education and related services, at public expense, for greater than 50 percent of the school day in public or private residential facilities. This may include children placed in:

• public and private residential schools for students with disabilities; or

• public and private residential schools for students with disabilities for a portion of the school day (greater than 50 percent) and in separate day schools or regular school buildings for the remainder of the school day.

Do not include students who received education programs at the facility, but do not live there.

Column F. Homebound/Hospital. Unduplicated total who received education programs in homebound/hospital environment includes children with disabilities placed in and receiving special education and related services in:

• hospital programs, or

• homebound programs.

Do not include children with disabilities whose parents have opted to home-school them and who receive special education at the public expense.

Column G. Correctional facilities. Unduplicated total who received special education in correctional facilities. These data are intended to be a count of all children receiving special education in:

• short-term detention facilities (community-based or residential), or

• correctional facilities.

Column H. Parentally Placed in Private Schools. Unduplicated total who have been enrolled by their parents or guardians in regular parochial or other private schools and whose basic education is paid through private resources and who receive special education and related services at public expense from a local educational agency or intermediate educational unit under a service plan.² Include children whose parents chose to home-school them, but who receive special education and related services at the public expense. Do not include children who are placed in private schools by the LEA.

Section G: Race/Ethnicity of Children with Disabilities Ages 6-21 by Educational Environment

REPORT AN UNDUPLICATED COUNT OF ALL CHILDREN AGES 6-21 WITH DISABILITIES SERVED UNDER IDEA, PART B BY RACE/ETHNICITY AND EDUCATIONAL ENVIRONMENT. THE TOTAL DATA REPORTED ON EACH LINE IN SECTION F MUST EQUAL THE TOTAL DATA REPORTED IN THE CORRESPONDING EDUCATIONAL ENVIRONMENT IN SECTION E.

Use the environment categories defined under Section F and the race/ethnicity categories as defined in Section C.

Section H: Gender of Children with Disabilities Ages 6-21 by Educational Environment

REPORT AN UNDUPLICATED COUNT OF ALL CHILDREN AGES 6-21 WITH DISABILITIES SERVED UNDER IDEA, PART B BY GENDER AND EDUCATIONAL ENVIRONMENT. THE TOTAL DATA REPORTED ON EACH LINE IN SECTION G MUST EQUAL THE TOTAL DATA REPORTED IN THE CORRESPONDING EDUCATIONAL ENVIRONMENT IN SECTION F.

Use the environment categories defined in the instructions for Section F.

To reduce data burden, gender data for children ages 6-21 are not collected separately on the child count report. Totals on the educational environments report must equal the total number of children with disabilities ages 6-21 reported on the child count.

Section I: Limited English Proficiency Status of Children with Disabilities Ages 6-21 by Educational Environment

REPORT AN UNDUPLICATED COUNT OF ALL CHILDREN AGES 3-5 WITH DISABILITIES SERVED UNDER IDEA, PART B BY LIMITED ENGLISH PROFIENCY STATUS AND EDUCATIONAL ENVIRONMENT. THE TOTAL DATA REPORTED ON EACH LINE IN SECTION H MUST EQUAL THE TOTAL DATA REPORTED IN THE CORRESPONDING EDUCATIONAL ENVIRONMENT IN SECTION F.

Use the environment categories defined under Section F and the LEP categories as defined in the instructions for Section E.

To reduce data burden, LEP status data on children ages 6-21 are not collected separately on the child count report. Totals on the educational environments report must equal the total number of children with disabilities ages 6-21 reported on the child count.

U.S. DEPARTMENT OF EDUCATION PAGE 1 OF 22

OFFICE OF SPECIAL EDUCATION TABLE 3

AND REHABILITATIVE SERVICES OMB NO.: 1820-0517

OFFICE OF SPECIAL EDUCATION PART B, INDIVIDUALS WITH DISABILITIES EDUCATION ACT

PROGRAMS IMPLEMENTATION OF FAPE REQUIREMENTS FORM EXPIRES: X/XX/XXXX

2006

STATE: ____________________

SECTION A: DISCRETE AGE OF CHILDREN WITH DISABILITIES AGES 3-5 BY EDUCATIONAL ENVIRONMENT

EDUCATIONAL ENVIRONMENT:			AGE
			3	4	5	Total
(A) CHILDREN ATTENDING A REGULAR EARLY CHILDHOOD PROGRAM		(A1) IN THE REGULAR EARLY CHILDHOOD PROGRAM AT LEAST 80% OF TIME
		(A2) IN THE REGULAR EARLY CHILDHOOD PROGRAM 40% TO 79% OF TIME
		(A3) IN THE REGULAR EARLY CHILDHOOD PROGRAM LESS THAN 40% TIME
(B) CHILDREN NOT ATTENDING A REGULAR EARLY CHILDHOOD PROGRAM OR KINDERGARTEN	ATTENDING A SPECIAL EDUCATION PROGRAM:	(B1) SEPARATE CLASS
		(B2) SEPARATE SCHOOL
		(B3) RESIDENTIAL FACILITY
	NOT ATTENDING A SPECIAL EDUCATION PROGRAM:	(B4) HOME
		(B5) SERVICE PROVIDER LOCATION
(C) TOTAL (OF ROWS A1 – B5)

ED FORM: 869-4

U.S. DEPARTMENT OF EDUCATION PAGE 2 OF 22

OFFICE OF SPECIAL EDUCATION TABLE 3 (continued)

AND REHABILITATIVE SERVICES OMB NO.: 1820-0517

OFFICE OF SPECIAL EDUCATION PART B, INDIVIDUALS WITH DISABILITIES EDUCATION ACT

PROGRAMS IMPLEMENTATION OF FAPE REQUIREMENTS FORM EXPIRES: X/XX/XXXX

2006

STATE: ____________________

SECTION B: EDUCATIONAL ENVIRONMENT OF CHILDREN WITH DISABILITIES AGES 3-5 BY DISABILITY

DISABILITY	(A) CHILDREN ATTENDING A REGULAR EARLY CHILDHOOD PROGRAM OR KINDERGARTEN
	(A1) IN THE REGULAR EARLY CHILDHOOD PROGRAM AT LEAST 80% TIME	(A2) IN THE REGULAR EARLY CHILDHOOD PROGRAM 40% TO 79% TIME	(A3) IN THE REGULAR EARLY CHILDHOOD PROGRAM LESS THAN 40% TIME
MENTAL RETARDATION
HEARING IMPAIRMENTS
SPEECH OR LANGUAGE IMPAIRMENTS
VISUAL IMPAIRMENTS
EMOTIONAL DISTURBANCE
ORTHOPEDIC IMPAIRMENTS
OTHER HEALTH IMPAIRMENTS
SPECIFIC LEARNING DISABILITIES
DEAF-BLINDNESS
MULTIPLE DISABILITIES
AUTISM
TRAUMATIC BRAIN INJURY
DEVELOPMENTAL DELAY1
TOTAL:

¹ States must have defined and established eligibility criteria for developmental delay in order to use this category for reporting.

ED FORM: 869-4

U.S. DEPARTMENT OF EDUCATION PAGE 3 OF 22

OFFICE OF SPECIAL EDUCATION TABLE 3 (continued)

AND REHABILITATIVE SERVICES OMB NO.: 1820-0517

OFFICE OF SPECIAL EDUCATION PART B, INDIVIDUALS WITH DISABILITIES EDUCATION ACT

PROGRAMS IMPLEMENTATION OF FAPE REQUIREMENTS FORM EXPIRES: X/XX/XXXX

2006

STATE: ____________________

SECTION B (CONTINUED)

DISABILITY	(B) CHILDREN NOT ATTENDING A REGULAR EARLY CHILDHOOOD PROGRAM OR KINDERGARTEN
	ONLY ATTENDING A SPECIAL EDUCATION PROGRAM			NOT ATTENDING A SPECIAL EDUCATION PROGRAM
	(B1) SEPARATE CLASS	(B2) SEPARATE SCHOOL	(B3) RESIDENTIAL FACILITY	(B4) HOME	(B5) SERVICE PROVIDER LOCATION
MENTAL RETARDATION
HEARING IMPAIRMENTS
SPEECH OR LANGUAGE IMPAIRMENTS
VISUAL IMPAIRMENTS
EMOTIONAL DISTURBANCE
ORTHOPEDIC IMPAIRMENTS
OTHER HEALTH IMPAIRMENTS
SPECIFIC LEARNING DISABILITIES
DEAF-BLINDNESS
MULTIPLE DISABILITIES
AUTISM
TRAUMATIC BRAIN INJURY
DEVELOPMENTAL DELAY1
TOTAL:

¹ States must have defined and established eligibility criteria for developmental delay in order to use this category for reporting.

ED FORM: 869-4

U.S. DEPARTMENT OF EDUCATION PAGE 4 OF 22

OFFICE OF SPECIAL EDUCATION TABLE 3 (continued)

AND REHABILITATIVE SERVICES OMB NO.: 1820-0517

OFFICE OF SPECIAL EDUCATION PART B, INDIVIDUALS WITH DISABILITIES EDUCATION ACT

PROGRAMS IMPLEMENTATION OF FAPE REQUIREMENTS FORM EXPIRES: X/XX/XXXX

2006

STATE: ____________________

SECTION B (CONTINUED)

DISABILITY	(A) CHILDREN ATTENDING A REGULAR EARLY CHILDHOOD PROGRAM OR KINDERGARTEN (PERCENT)1
	(A1) IN THE REGULAR EARLY CHILDHOOD PROGRAM AT LEAST 80% TIME (PERCENT)	(A2) IN THE REGULAR EARLY CHILDHOOD PROGRAM 40% TO 79% TIME (PERCENT)	(A3) IN THE REGULAR EARLY CHILDHOOD PROGRAM LESS THAN 40% TIME (PERCENT)
MENTAL RETARDATION
HEARING IMPAIRMENTS
SPEECH OR LANGUAGE IMPAIRMENTS
VISUAL IMPAIRMENTS
EMOTIONAL DISTURBANCE
ORTHOPEDIC IMPAIRMENTS
OTHER HEALTH IMPAIRMENTS
SPECIFIC LEARNING DISABILITIES
DEAF-BLINDNESS
MULTIPLE DISABILITIES
AUTISM
TRAUMATIC BRAIN INJURY
DEVELOPMENTAL DELAY2
TOTAL:	100%	100%	100%

¹ STATES SHOULD NOT PROVIDE PERCENTAGES IN THIS SECTION, AS THEY WILL BE CALCULATED AFTER THE COUNTS ARE SUBMITTED.

² States must have defined and established eligibility criteria for developmental delay in order to use this category for reporting.

ED FORM: 869-4

U.S. DEPARTMENT OF EDUCATION PAGE 5 OF 22

OFFICE OF SPECIAL EDUCATION TABLE 3 (continued)

AND REHABILITATIVE SERVICES OMB NO.: 1820-0517

OFFICE OF SPECIAL EDUCATION PART B, INDIVIDUALS WITH DISABILITIES EDUCATION ACT

PROGRAMS IMPLEMENTATION OF FAPE REQUIREMENTS FORM EXPIRES: X/XX/XXXX

2006

STATE: ____________________

SECTION B (continued)

DISABILITY	(B) CHILDREN NOT ATTENDING A REGULAR EARLY CHILDHOOOD PROGRAM OR KINDERGARTEN (PERCENT)1
	ONLY ATTENDING A SPECIAL EDUCATION PROGRAM			ONLY ATTENDING A SPECIAL EDUCATION PROGRAM
	(B1) SEPARATE CLASS (PERCENT)	(B2) SEPARATE SCHOOL (PERCENT)	(B3) RESIDENTIAL FACILITY (PERCENT)	(B4) HOME (PERCENT)	(B5) SERVICE PROVIDER LOCATION (PERCENT)
MENTAL RETARDATION
HEARING IMPAIRMENTS
SPEECH OR LANGUAGE IMPAIRMENTS
VISUAL IMPAIRMENTS
EMOTIONAL DISTURBANCE
ORTHOPEDIC IMPAIRMENTS
OTHER HEALTH IMPAIRMENTS
SPECIFIC LEARNING DISABILITIES
DEAF-BLINDNESS
MULTIPLE DISABILITIES
AUTISM
TRAUMATIC BRAIN INJURY
DEVELOPMENTAL DELAY2
TOTAL:	100%	100%	100%	100%	100%

¹ STATES SHOULD NOT PROVIDE PERCENTAGES IN THIS SECTION, AS THEY WILL BE CALCULATED AFTER THE COUNTS ARE SUBMITTED.

²States must have defined and established eligibility criteria for developmental delay in order to use this category for reporting.

ED FORM: 869-4

U.S. DEPARTMENT OF EDUCATION PAGE 6 OF 22

OFFICE OF SPECIAL EDUCATION TABLE 3 (continued)

AND REHABILITATIVE SERVICES OMB NO.: 1820-0517

OFFICE OF SPECIAL EDUCATION PART B, INDIVIDUALS WITH DISABILITIES EDUCATION ACT

PROGRAMS IMPLEMENTATION OF FAPE REQUIREMENTS FORM EXPIRES: X/XX/XXXX

2006

STATE: ____________________

SECTION C: RACE/ETHNICITY OF CHILDREN WITH DISABILITIES AGES 3-5 BY EDUCATIONAL ENVIRONMENT

EDUCATIONAL ENVIRONMENT:			RACE/ETHNICITY
			AMERICAN INDIAN OR ALASKA NATIVE	ASIAN OR OTHER PACIFIC ISLANDER	BLACK (Not Hispanic)	HISPANIC	WHITE (Not Hispanic)	TOTAL
(A) CHILDREN ATTENDING A REGULAR EARLY CHILDHOOD PROGRAM		(A1) IN THE REGULAR EARLY CHILDHOOD PROGRAM AT LEAST 80% OF TIME
		(A2) IN THE REGULAR EARLY CHILDHOOD PROGRAM 40% TO 79% OF TIME
		(A3) IN THE REGULAR EARLY CHILDHOOD PROGRAM LESS THAN 40% TIME
(B) CHILDREN NOT ATTENDING A REGULAR EARLY CHILDHOOD PROGRAM OR KINDERGARTEN	ATTENDING A SPECIAL EDUCATION PROGRAM:	(B1) SEPARATE CLASS
		(B2) SEPARATE SCHOOL
		(B3) RESIDENTIAL FACILITY
	NOT ATTENDING A SPECIAL EDUCATION PROGRAM:	(B4) HOME
		(B5) SERVICE PROVIDER LOCATION
(C) TOTAL (OF ROWS A1 – B5)

ED FORM: 869-4

U.S. DEPARTMENT OF EDUCATION PAGE 7 OF 22

OFFICE OF SPECIAL EDUCATION TABLE 3 (continued)

AND REHABILITATIVE SERVICES OMB NO.: 1820-0517

OFFICE OF SPECIAL EDUCATION PART B, INDIVIDUALS WITH DISABILITIES EDUCATION ACT

PROGRAMS IMPLEMENTATION OF FAPE REQUIREMENTS FORM EXPIRES: X/XX/XXXX

2006

STATE: ____________________

SECTION C (CONTINUED)

EDUCATIONAL ENVIRONMENT:			RACE/ETHNICITY (PERCENT)1
			AMERICAN INDIAN OR ALASKA NATIVE (PERCENT)	ASIAN OR OTHER PACIFIC ISLANDER (PERCENT)	BLACK (Not Hispanic) (PERCENT)	HISPANIC (PERCENT)	WHITE (Not Hispanic) (PERCENT)	TOTAL (PERCENT)
(A) CHILDREN ATTENDING A REGULAR EARLY CHILDHOOD PROGRAM		(A1) IN THE REGULAR EARLY CHILDHOOD PROGRAM AT LEAST 80% OF TIME						100%
		(A2) IN THE REGULAR EARLY CHILDHOOD PROGRAM 40% TO 79% OF TIME						100%
		(A3) IN THE REGULAR EARLY CHILDHOOD PROGRAM LESS THAN 40% TIME						100%
(B) CHILDREN NOT ATTENDING A REGULAR EARLY CHILDHOOD PROGRAM OR KINDERGARTEN	ATTENDING A SPECIAL EDUCATION PROGRAM:	(B1) SEPARATE CLASS						100%
		(B2) SEPARATE SCHOOL						100%
		(B3) RESIDENTIAL FACILITY						100%
	NOT ATTENDING A SPECIAL EDUCATION PROGRAM:	(B4) HOME						100%
		(B5) SERVICE PROVIDER LOCATION						100%

¹ STATES SHOULD NOT PROVIDE PERCENTAGES IN THIS SECTION, AS THEY WILL BE CALCULATED AFTER THE COUNTS ARE SUBMITTED.

ED FORM: 869-4

U.S. DEPARTMENT OF EDUCATION PAGE 8 OF 22

OFFICE OF SPECIAL EDUCATION TABLE 3 (continued)

AND REHABILITATIVE SERVICES OMB NO.: 1820-0517

OFFICE OF SPECIAL EDUCATION PART B, INDIVIDUALS WITH DISABILITIES EDUCATION ACT

PROGRAMS IMPLEMENTATION OF FAPE REQUIREMENTS FORM EXPIRES: X/XX/XXXX

2006

STATE: ____________________

SECTION D: GENDER OF CHILDREN WITH DISABILITIES AGES 3-5 BY EDUCATIONAL ENVIRONMENT

EDUCATIONAL ENVIRONMENT:			GENDER
			MALE	FEMALE	TOTAL
(A) CHILDREN ATTENDING A REGULAR EARLY CHILDHOOD PROGRAM		(A1) IN THE REGULAR EARLY CHILDHOOD PROGRAM AT LEAST 80% OF TIME
		(A2) IN THE REGULAR EARLY CHILDHOOD PROGRAM 40% TO 79% OF TIME
		(A3) IN THE REGULAR EARLY CHILDHOOD PROGRAM LESS THAN 40% TIME
(B) CHILDREN NOT ATTENDING A REGULAR EARLY CHILDHOOD PROGRAM OR KINDERGARTEN	ATTENDING A SPECIAL EDUCATION PROGRAM:	(B1) SEPARATE CLASS
		(B2) SEPARATE SCHOOL
		(B3) RESIDENTIAL FACILITY
	NOT ATTENDING A SPECIAL EDUCATION PROGRAM:	(B4) HOME
		(B5) SERVICE PROVIDER LOCATION
(C) TOTAL (OF ROWS A1 – B5)

ED FORM: 869-4

U.S. DEPARTMENT OF EDUCATION PAGE 9 OF 22

OFFICE OF SPECIAL EDUCATION TABLE 3 (continued)

AND REHABILITATIVE SERVICES OMB NO.: 1820-0517

OFFICE OF SPECIAL EDUCATION PART B, INDIVIDUALS WITH DISABILITIES EDUCATION ACT

PROGRAMS IMPLEMENTATION OF FAPE REQUIREMENTS FORM EXPIRES: X/XX/XXXX

2006

STATE: ____________________

SECTION D (CONTINUED)

EDUCATIONAL ENVIRONMENT:			GENDER
			MALE (PERCENT)	FEMALE (PERCENT)	TOTAL (PERCENT)
(A) CHILDREN ATTENDING A REGULAR EARLY CHILDHOOD PROGRAM		(A1) IN THE REGULAR EARLY CHILDHOOD PROGRAM AT LEAST 80% OF TIME			100%
		(A2) IN THE REGULAR EARLY CHILDHOOD PROGRAM 40% TO 79% OF TIME			100%
		(A3) IN THE REGULAR EARLY CHILDHOOD PROGRAM LESS THAN 40% TIME			100%
(B) CHILDREN NOT ATTENDING A REGULAR EARLY CHILDHOOD PROGRAM OR KINDERGARTEN	ATTENDING A SPECIAL EDUCATION PROGRAM:	(B1) SEPARATE CLASS			100%
		(B2) SEPARATE SCHOOL			100%
		(B3) RESIDENTIAL FACILITY			100%
	NOT ATTENDING A SPECIAL EDUCATION PROGRAM:	(B4) HOME			100%
		(B5) SERVICE PROVIDER LOCATION			100%
(C) TOTAL (OF ROWS A1 – B5)					100%

¹ STATES SHOULD NOT PROVIDE PERCENTAGES IN THIS SECTION, AS THEY WILL BE CALCULATED AFTER THE COUNTS ARE SUBMITTED.

ED FORM: 869-4

U.S. DEPARTMENT OF EDUCATION PAGE 10 OF 22

OFFICE OF SPECIAL EDUCATION TABLE 3 (continued)

AND REHABILITATIVE SERVICES OMB NO.: 1820-0517

OFFICE OF SPECIAL EDUCATION PART B, INDIVIDUALS WITH DISABILITIES EDUCATION ACT

PROGRAMS IMPLEMENTATION OF FAPE REQUIREMENTS FORM EXPIRES: X/XX/XXXX

2006

STATE: ____________________

SECTION E: LIMITED ENGLISH PROFIENCY STATUS OF CHILDREN WITH DISABILITIES AGES 3-5 BY EDUCATIONAL ENVIRONMENT

EDUCATIONAL ENVIRONMENT:			LIMITED ENGLISH PROFICIENCY STATUS
			YES	NO	TOTAL
(A) CHILDREN ATTENDING A REGULAR EARLY CHILDHOOD PROGRAM		(A1) IN THE REGULAR EARLY CHILDHOOD PROGRAM AT LEAST 80% OF TIME
		(A2) IN THE REGULAR EARLY CHILDHOOD PROGRAM 40% TO 79% OF TIME
		(A3) IN THE REGULAR EARLY CHILDHOOD PROGRAM LESS THAN 40% TIME
(B) CHILDREN NOT ATTENDING A REGULAR EARLY CHILDHOOD PROGRAM OR KINDERGARTEN	ATTENDING A SPECIAL EDUCATION PROGRAM:	(B1) SEPARATE CLASS
		(B2) SEPARATE SCHOOL
		(B3) RESIDENTIAL FACILITY
	NOT ATTENDING A SPECIAL EDUCATION PROGRAM:	(B4) HOME
		(B5) SERVICE PROVIDER LOCATION
(C) TOTAL (OF ROWS A1 – B5)

ED FORM: 869-4

U.S. DEPARTMENT OF EDUCATION PAGE 11 OF 22

OFFICE OF SPECIAL EDUCATION TABLE 3 (continued)

AND REHABILITATIVE SERVICES OMB NO.: 1820-0517

OFFICE OF SPECIAL EDUCATION PART B, INDIVIDUALS WITH DISABILITIES EDUCATION ACT

PROGRAMS IMPLEMENTATION OF FAPE REQUIREMENTS FORM EXPIRES: X/XX/XXXX

2006

STATE: ____________________

SECTION E (CONTINUED)

EDUCATIONAL ENVIRONMENT:			LIMITED ENGLISH PROFICIENCY STATUS
			YES (PERCENT)	NO (PERCENT)	TOTAL (PERCENT)
(A) CHILDREN ATTENDING A REGULAR EARLY CHILDHOOD PROGRAM		(A1) IN THE REGULAR EARLY CHILDHOOD PROGRAM AT LEAST 80% OF TIME			100%
		(A2) IN THE REGULAR EARLY CHILDHOOD PROGRAM 40% TO 79% OF TIME			100%
		(A3) IN THE REGULAR EARLY CHILDHOOD PROGRAM LESS THAN 40% TIME			100%
(B) CHILDREN NOT ATTENDING A REGULAR EARLY CHILDHOOD PROGRAM OR KINDERGARTEN	ATTENDING A SPECIAL EDUCATION PROGRAM:	(B1) SEPARATE CLASS			100%
		(B2) SEPARATE SCHOOL			100%
		(B3) RESIDENTIAL FACILITY			100%
	NOT ATTENDING A SPECIAL EDUCATION PROGRAM:	(B4) HOME			100%
		(B5) SERVICE PROVIDER LOCATION			100%
(C) TOTAL (OF ROWS A1 – B5)					100%

¹ STATES SHOULD NOT PROVIDE PERCENTAGES IN THIS SECTION, AS THEY WILL BE CALCULATED AFTER THE COUNTS ARE SUBMITTED.

ED FORM: 869-4

U.S. DEPARTMENT OF EDUCATION PAGE 12 OF 22

OFFICE OF SPECIAL EDUCATION TABLE 3 (continued)

AND REHABILITATIVE SERVICES OMB NO.: 1820-0517

OFFICE OF SPECIAL EDUCATION PART B, INDIVIDUALS WITH DISABILITIES EDUCATION ACT

PROGRAMS IMPLEMENTATION OF FAPE REQUIREMENTS FORM EXPIRES: X/XX/XXXX

2006

STATE: ____________________

SECTION F: EDUCATIONAL ENVIRONMENT AND AGE CATEGORY OF CHILDREN WITH DISABILITIES AGES 6-21 BY DISABILITY

DISABILITY	(A) INSIDE THE REGULAR CLASS 80% OR MORE OF DAY			(B) INSIDE THE REGULAR CLASS NO MORE THAN 79% OF DAY BUT NO LESS THAN 40% OF DAY
	(1) 6-11	(2) 12-17	(3) 18-21	(4) 6-11	(5) 12-17	(6) 18-21
MENTAL RETARDATION
HEARING IMPAIRMENTS
SPEECH OR LANGUAGE IMPAIRMENTS
VISUAL IMPAIRMENTS
EMOTIONAL DISTURBANCE
ORTHOPEDIC IMPAIRMENTS
OTHER HEALTH IMPAIRMENTS
SPECIFIC LEARNING DISABILITIES
DEAF-BLINDNESS
MULTIPLE DISABILITIES
AUTISM
TRAUMATIC BRAIN INJURY
DEVELOPMENTAL DELAY1
TOTAL:

¹ States must have defined and established eligibility criteria for developmental delay in order to use this category for reporting.

ED FORM: 869-4

U.S. DEPARTMENT OF EDUCATION PAGE 13 OF 22

OFFICE OF SPECIAL EDUCATION TABLE 3 (continued)

AND REHABILITATIVE SERVICES OMB NO.: 1820-0517

OFFICE OF SPECIAL EDUCATION PART B, INDIVIDUALS WITH DISABILITIES EDUCATION ACT

PROGRAMS IMPLEMENTATION OF FAPE REQUIREMENTS FORM EXPIRES:

2006

STATE: ____________________

SECTION F (CONTINUED)

DISABILITY	(C) INSIDE REGULAR CLASS FOR LESS THAN 40% OF DAY			(D) SEPARATE SCHOOL
	(7) 6-11	(8) 12-17	(9) 18-21	(10) 6-11	(11) 12-17	(12) 18-21
MENTAL RETARDATION
HEARING IMPAIRMENTS
SPEECH OR LANGUAGE IMPAIRMENTS
VISUAL IMPAIRMENTS
EMOTIONAL DISTURBANCE
ORTHOPEDIC IMPAIRMENTS
OTHER HEALTH IMPAIRMENTS
SPECIFIC LEARNING DISABILITIES
DEAF-BLINDNESS
MULTIPLE DISABILITIES
AUTISM
TRAUMATIC BRAIN INJURY
DEVELOPMENTAL DELAY1
TOTAL:

¹States must have defined and established eligibility criteria for developmental delay in order to use this category for reporting.

ED FORM: 869-4

U.S. DEPARTMENT OF EDUCATION PAGE 14 OF 22

OFFICE OF SPECIAL EDUCATION TABLE 3 (continued)

AND REHABILITATIVE SERVICES OMB NO.: 1820-0517

OFFICE OF SPECIAL EDUCATION PART B, INDIVIDUALS WITH DISABILITIES EDUCATION ACT

PROGRAMS IMPLEMENTATION OF FAPE REQUIREMENTS FORM EXPIRES:

2006

STATE: ____________________

SECTION F (CONTINUED)

DISABILITY	(E) RESIDENTIAL FACILITY			(F) HOMEBOUND/HOSPITAL
	(13) 6-11	(14) 12-17	(15) 18-21	(16) 6-11	(17) 12-17	(18) 18-21
MENTAL RETARDATION
HEARING IMPAIRMENTS
SPEECH OR LANGUAGE IMPAIRMENTS
VISUAL IMPAIRMENTS
EMOTIONAL DISTURBANCE
ORTHOPEDIC IMPAIRMENTS
OTHER HEALTH IMPAIRMENTS
SPECIFIC LEARNING DISABILITIES
DEAF-BLINDNESS
MULTIPLE DISABILITIES
AUTISM
TRAUMATIC BRAIN INJURY
DEVELOPMENTAL DELAY1
TOTAL:

¹ States must have defined and established eligibility criteria for developmental delay in order to use this category for reporting.

ED FORM: 869-4

U.S. DEPARTMENT OF EDUCATION PAGE 15 OF 22

OFFICE OF SPECIAL EDUCATION TABLE 3 (continued)

AND REHABILITATIVE SERVICES OMB NO.: 1820-0517

OFFICE OF SPECIAL EDUCATION PART B, INDIVIDUALS WITH DISABILITIES EDUCATION ACT

PROGRAMS IMPLEMENTATION OF FAPE REQUIREMENTS FORM EXPIRES:

2006

STATE: ____________________

SECTION F (CONTINUED)

DISABILITY	(G) CORRECTIONAL FACILITIES			(H) PARENTALLY PLACED IN PRIVATE SCHOOLS
	(19) 6-11	(20) 12-17	(21) 18-21	(22) 6-11	(23) 12-17	(24) 18-21
MENTAL RETARDATION
HEARING IMPAIRMENTS
SPEECH OR LANGUAGE IMPAIRMENTS
VISUAL IMPAIRMENTS
EMOTIONAL DISTURBANCE
ORTHOPEDIC IMPAIRMENTS
OTHER HEALTH IMPAIRMENTS
SPECIFIC LEARNING DISABILITIES
DEAF-BLINDNESS
MULTIPLE DISABILITIES
AUTISM
TRAUMATIC BRAIN INJURY
DEVELOPMENTAL DELAY1
TOTAL:

¹ States must have defined and established eligibility criteria for developmental delay in order to use this category for reporting.

ED FORM: 869-4

U.S. DEPARTMENT OF EDUCATION PAGE 16 OF 22

OFFICE OF SPECIAL EDUCATION TABLE 3 (continued)

AND REHABILITATIVE SERVICES OMB NO.: 1820-0517

OFFICE OF SPECIAL EDUCATION PART B, INDIVIDUALS WITH DISABILITIES EDUCATION ACT

PROGRAMS IMPLEMENTATION OF FAPE REQUIREMENTS FORM EXPIRES:

2006

STATE: ____________________

SECTION F (CONTINUED)

DISABILITY	EDUCATIONAL ENVIRONMENT (PERCENT)1
	(A) INSIDE THE REGULAR CLASS 80% OR MORE OF DAY (PERCENT)	(B) INSIDE THE REGULAR CLASS 79-40% OF DAY (PERCENT)	(C) INSIDE THE REGULAR CLASS LESS THAN 40% OF DAY (PERCENT)	(D) SEPARATE CLASS (PERCENT)	(E) SEPARATE SCHOOL (PERCENT)	(F) HOMEBOUND/ HOSPITAL (PERCENT)	(G) CORRECTIONAL FACILITIES (PERCENT)	(H) PARENTALLY PLACED IN PRIVATE SCHOOLS (PERCENT)
MENTAL RETARDATION
HEARING IMPAIRMENTS
SPEECH OR LANGUAGE IMPAIRMENTS
VISUAL IMPAIRMENTS
EMOTIONAL DISTURBANCE
ORTHOPEDIC IMPAIRMENTS
OTHER HEALTH IMPAIRMENTS
SPECIFIC LEARNING DISABILITIES
DEAF-BLINDNESS
MULTIPLE DISABILITIES
AUTISM
TRAUMATIC BRAIN INJURY
DEVELOPMENTAL DELAY2
TOTAL:	100%	100%	100%	100%	100%	100%	100%	100%

¹ STATES SHOULD NOT PROVIDE PERCENTAGES IN THIS SECTION, AS THEY WILL BE CALCULATED AFTER THE COUNTS ARE SUBMITTED.

² States must have defined and established eligibility criteria for developmental delay in order to use this category for reporting.

ED FORM: 869-4

U.S. DEPARTMENT OF EDUCATION PAGE 17 OF 22

OFFICE OF SPECIAL EDUCATION TABLE 3 (continued)

AND REHABILITATIVE SERVICES OMB NO.: 1820-0517

OFFICE OF SPECIAL EDUCATION PART B, INDIVIDUALS WITH DISABILITIES EDUCATION ACT

PROGRAMS IMPLEMENTATION OF FAPE REQUIREMENTS FORM EXPIRES: X/XX/XXXX

2006

STATE: ____________________

SECTION G: RACE/ETHNICITY OF CHILDREN WITH DISABILITIES AGES 6-21 BY EDUCATIONAL ENVIRONMENT

EDUCATIONAL ENVIRONMENT	RACE/ETHNICITY
	AMERICAN INDIAN OR ALASKA NATIVE	ASIAN OR OTHER PACIFIC ISLANDER	BLACK (Not Hispanic)	HISPANIC	WHITE (Not Hispanic)	TOTAL
(A) INSIDE REGULAR CLASS 80% OR MORE OF DAY
(B) INSIDE REGULAR CLASS 79-40% OF DAY
(C) INSIDE REGULAR CLASS LESS THAN 40% OF DAY
(D) SEPARATE SCHOOL
(E) RESIDENTIAL FACILITY
(F) HOMEBOUND/HOSPITAL
(G) CORRECTIONAL FACILITIES
(H) PARENTALLY PLACED IN PRIVATE SCHOOLS
(I) TOTAL (OF ROWS A-H):

ED FORM: 869-4

U.S. DEPARTMENT OF EDUCATION PAGE 18 OF 22

OFFICE OF SPECIAL EDUCATION TABLE 3 (continued)

AND REHABILITATIVE SERVICES OMB NO.: 1820-0517

OFFICE OF SPECIAL EDUCATION PART B, INDIVIDUALS WITH DISABILITIES EDUCATION ACT

PROGRAMS IMPLEMENTATION OF FAPE REQUIREMENTS FORM EXPIRES: X/XX/XXXX

2006

STATE: ____________________

SECTION G (CONTINUED)

EDUCATIONAL ENVIRONMENT	RACE/ETHNICITY (PERCENT)1
	AMERICAN INDIAN OR ALASKA NATIVE (PERCENT)	ASIAN OR OTHER PACIFIC ISLANDER (PERCENT)	BLACK (Not Hispanic) (PERCENT)	HISPANIC (PERCENT)	WHITE (Not Hispanic) (PERCENT)	TOTAL (PERCENT)
(A) INSIDE REGULAR CLASS 80% OR MORE OF DAY						100%
(B) INSIDE REGULAR CLASS 79-40% OF DAY						100%
(C) INSIDE REGULAR CLASS LESS THAN 40% OF DAY						100%
(D) SEPARATE SCHOOL						100%
(E) RESIDENTIAL FACILITY						100%
(F) HOMEBOUND/HOSPITAL						100%
(G) CORRECTIONAL FACILITIES						100%
(H) PARENTALLY PLACED IN PRIVATE SCHOOLS						100%

¹ STATES SHOULD NOT PROVIDE PERCENTAGES IN THIS SECTION, AS THEY WILL BE CALCULATED AFTER THE COUNTS ARE SUBMITTED.

ED FORM: 869-4

U.S. DEPARTMENT OF EDUCATION PAGE 19 OF 22

OFFICE OF SPECIAL EDUCATION TABLE 3 (continued)

AND REHABILITATIVE SERVICES OMB NO.: 1820-0517

OFFICE OF SPECIAL EDUCATION PART B, INDIVIDUALS WITH DISABILITIES EDUCATION ACT

PROGRAMS IMPLEMENTATION OF FAPE REQUIREMENTS FORM EXPIRES: X/XX/XXXX

2006

STATE: ____________________

SECTION H: GENDER OF CHILDREN WITH DISABILITIES AGES 6-21 BY EDUCATIONAL ENVIRONMENT

EDUCATIONAL ENVIRONMENT	GENDER
	MALE	FEMALE	TOTAL
(A) INSIDE REGULAR CLASS 80% OR MORE OF DAY
(B) INSIDE REGULAR CLASS 79-40% OF DAY
(C) INSIDE REGULAR CLASS LESS THAN 40% OF DAY
(D) SEPARATE SCHOOL
(E) RESIDENTIAL FACILITY
(F) HOMEBOUND/HOSPITAL
(G) CORRECTIONAL FACILITIES
(H) PARENTALLY PLACED IN PRIVATE SCHOOLS
(I) TOTAL (OF ROWS A-H):

ED FORM: 869-4

U.S. DEPARTMENT OF EDUCATION PAGE 20 OF 22

OFFICE OF SPECIAL EDUCATION TABLE 3 (continued)

AND REHABILITATIVE SERVICES OMB NO.: 1820-0517

OFFICE OF SPECIAL EDUCATION PART B, INDIVIDUALS WITH DISABILITIES EDUCATION ACT

PROGRAMS IMPLEMENTATION OF FAPE REQUIREMENTS FORM EXPIRES: X/XX/XXXX

2006

STATE: ____________________

SECTION H (CONTINUED)

EDUCATIONAL ENVIRONMENT	GENDER (PERCENT)1
	MALE (PERCENT)	FEMALE (PERCENT)	TOTAL (PERCENT)
(A) INSIDE REGULAR CLASS 80% OR MORE OF DAY			100%
(B) INSIDE REGULAR CLASS 79-40% OF DAY			100%
(C) INSIDE REGULAR CLASS LESS THAN 40% OF DAY			100%
(D) SEPARATE SCHOOL			100%
(E) RESIDENTIAL FACILITY			100%
(F) HOMEBOUND/HOSPITAL			100%
(G) CORRECTIONAL FACILITIES			100%
(H) PARENTALLY PLACED IN PRIVATE SCHOOLS			100%
(I) TOTAL (OF ROWS A-H):			100%

¹ STATES SHOULD NOT PROVIDE PERCENTAGES IN THIS SECTION, AS THEY WILL BE CALCULATED AFTER THE COUNTS ARE SUBMITTED.

ED FORM: 869-4

U.S. DEPARTMENT OF EDUCATION PAGE 21 OF 22

OFFICE OF SPECIAL EDUCATION TABLE 3 (continued)

AND REHABILITATIVE SERVICES OMB NO.: 1820-0517

OFFICE OF SPECIAL EDUCATION PART B, INDIVIDUALS WITH DISABILITIES EDUCATION ACT

PROGRAMS IMPLEMENTATION OF FAPE REQUIREMENTS FORM EXPIRES: X/XX/XXXX

2006

STATE: ____________________

SECTION I: LIMITED ENGLISH PROFIENCY STATUS OF CHILDREN WITH DISABILITIES AGES 6-21 BY EDUCATIONAL ENVIRONMENT

EDUCATIONAL ENVIRONMENT	LIMITED ENGLISH PROFIENCY STATUS
	YES	NO	TOTAL
(A) INSIDE REGULAR CLASS 80% OR MORE OF DAY
(B) INSIDE REGULAR CLASS 79-40% OF DAY
(C) INSIDE REGULAR CLASS LESS THAN 40% OF DAY
(D) SEPARATE SCHOOL
(E) RESIDENTIAL FACILITY
(F) HOMEBOUND/HOSPITAL
(G) CORRECTIONAL FACILITIES
(H) PARENTALLY PLACED IN PRIVATE SCHOOLS
(I) TOTAL (OF ROWS A-H):

ED FORM: 869-4

U.S. DEPARTMENT OF EDUCATION PAGE 22 OF 22

OFFICE OF SPECIAL EDUCATION TABLE 3 (continued)

AND REHABILITATIVE SERVICES OMB NO.: 1820-0517

OFFICE OF SPECIAL EDUCATION PART B, INDIVIDUALS WITH DISABILITIES EDUCATION ACT

PROGRAMS IMPLEMENTATION OF FAPE REQUIREMENTS FORM EXPIRES: X/XX/XXXX

2006

STATE: ____________________

SECTION I (CONTINUED)

EDUCATIONAL ENVIRONMENT	LIMITED ENGLISH PROFIENCY STATUS (PERCENT)1
	YES (PERCENT)	NO (PERCENT)	TOTAL (PERCENT)
(A) INSIDE REGULAR CLASS 80% OR MORE OF DAY			100%
(B) INSIDE REGULAR CLASS 79-40% OF DAY			100%
(C) INSIDE REGULAR CLASS LESS THAN 40% OF DAY			100%
(D) SEPARATE SCHOOL			100%
(E) RESIDENTIAL FACILITY			100%
(F) HOMEBOUND/HOSPITAL			100%
(G) CORRECTIONAL FACILITIES			100%
(H) PARENTALLY PLACED IN PRIVATE SCHOOLS			100%
(I) TOTAL (OF ROWS A-H):			100%

¹ STATES SHOULD NOT PROVIDE PERCENTAGES IN THIS SECTION, AS THEY WILL BE CALCULATED AFTER THE COUNTS ARE SUBMITTED.

ED FORM: 869-4

1The reporting of data on developmental delay is optional. Only children ages 3 through 9 may be reported in the developmental delay disability category and then only in States with the diagnostic instruments and procedures to measure delays in physical, cognitive, communication, social or emotional, or adaptive development. States must have defined and established eligibility criteria for developmental delay in order to report children in this category. Although Federal law does not require that States and LEAs categorize children according to developmental delay, if this category is required by State law, States are expected to report these children in the developmental delay category.

2² A private institution or school is a school NOT under Federal or public supervision or control and may be non-profit or proprietary.