Part B IDEA Implementation of FAPE Requirements

Page 11 of 11

TABLE 3 - RE7 (for reporting race/ethnicity according to New 10/2007 Guidance)

PART B, INDIVIDUALS WITH DISABILITIES EDUCATION ACT

IMPLEMENTATION OF FAPE REQUIREMENTS

Child Count Date for 2010

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 26 hours per SEA and 26 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.

For States that have been approved for EDFacts-only submission, the State EDFacts Coordinators will follow the data submission instructions they have been provided. All other States must submit electronic versions of the completed data forms to OSEP’s data contractor at [email protected]. OSEP will provide electronic Data Transmission Spreadsheets (DTS) in Microsoft Excel format to facilitate this process. States that are approved to submit these data through EDFacts only are not required to use the DTS. Nevertheless, all States will receive the DTS as a courtesy as they may assist in preparing the data for submission.

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 2, 2011

Sampling Allowed: No

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, 2010 and December 1, 2010 (inclusive), and that date should remain consistent each year.² 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.

In providing data for this collection, the State is to submit complete and unsuppressed data.

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

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.

The reporting categories below distinguish between children participating in regular early childhood programs, in special education programs, or in neither a regular early childhood program nor a special education program. In addition, the reporting categories distinguish where children receive the majority of their special education and related services.

Use the following decision rules to determine the appropriate educational environment category for reporting each 3- through 5-year old. Please note that the order of the categories as listed on the table for reporting children with disabilities ages 3-5 does not reflect a continuum from least to most restrictive. Selection of the appropriate reporting category involves a multi-stage procedure – identifying (in column 1) the type of program the child attends, if any, (and the number of hours per week in attendance for Row Set A), then further identifying (in column 2) the setting in which the child receives the majority of special education and related services.

1. The first factor to consider (column 1) is whether the child is attending a Regular Early Childhood Program, as defined below.

Regular Early Childhood Program. A Regular Early Childhood Program is a program that includes a majority (at least 50 percent) of nondisabled children (i.e., children not on IEP’s). This category may include, but is not limited to:

• Head Start;

• kindergartens;

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

• private kindergartens³ or preschools; and

• group child development center or child care.

If the child is attending a Regular Early Childhood Program, s/he is to be reported within either Row Set A (A1 or A2) or Row Set B (B1 or B2), as directed below. If the child does not attend a Regular Early Childhood Program at all, skip to instruction #2, below.

Children attending Regular Early Childhood Programs are then classified into one of two subcategories:

Under column 1:

Row set A is for reporting children attending a Regular Early Childhood Program at least 10 hours per week;

If the child attends a Regular Early Childhood Program at least 10 hours per week, refer to the criteria listed under instruction #3, titled ‘Reporting Special Education and Related Services Environment,’ on the next page, to identify which of categories A1 or A2 (under column 2) best represents the environment in which the child receives the majority of hours of special education and related services.

Row set B is for reporting children attending a Regular Early Childhood Program less than 10 hours per week.

If the child attends a Regular Early Childhood Program less than 10 hours per week, refer to the criteria listed in instruction #3, titled ‘Reporting Special Education and Related Services Environment,’ on the next page, to identify which of categories B1 or B2 (under column 2) best represents the environment in which the child receives the majority of hours of special education and related services.

2. If the child is NOT at all attending a Regular Early Childhood Program as defined above, the child is to be reported within either Row Set C or Row Set D. Such children would be either ‘Attending a Special Education Program (row C1, C2, or C3), OR ‘Attending Neither a Regular Early Childhood Education Program Nor a Special Education Program’ of any kind, in which case the child would be receiving special education and related services either at Home (row D1) or in a Service Provider Location or some Other Location (row D2).

If the child attends a Special Education Program, as defined below, report the child in row C1, C2, or C3.

Special education program. A Special Education Program includes less than 50 percent nondisabled children (i.e., children not on IEP’s). Special education programs include, but are not limited to:

• 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.

Report the child in one of the three bulleted environments listed just above, even if the child also receives special education services in the home (row D1) or in the service provider location or some other location (row D2).

If the child attends neither a Regular Early Childhood Program nor a Special Education Program as defined above, the child is to be reported in either row D1 or D2, dependent upon whether the child receives special education and related services at home (row D1) or in the service provider location or some other location (row D2), as respectively described below:

• (D1) Home. If the child attends neither a Regular Early Childhood Program nor a Special Education Program, the next factor to consider is whether the child receives some or all of his/her special education and related services in the home. Report the child in this category (D1), even if the child also receives special education and related services in a service provider location or some other location that is not in any other category (D2).

• (D2) Service Provider location or some other location not in any other category. If the child attends neither a Regular Early Childhood Program nor a Special Education Program and does not receive any special education and related services in the home, report the child in row D2.

3. Reporting Special Education and Related Services Environment

If you report that a child attends a Regular Early Childhood Program, you must also select the category (in column 2) that best represents the environment in which the child receives the majority of hours of special education and related services and the number of hours that the child spends in the Regular Early Childhood Program each week.

The educational environment categories are as follows:

Row A1. The child is receiving the majority of hours of special education and related services in the Regular Early Childhood Program (and the child attends a Regular Early Childhood Program at least 10 hours per week).

Row A2. The child is receiving the majority of hours of special education and related services in some other location (and the child attends a Regular Early Childhood Program at least 10 hours per week).

Row B1. The child is receiving the majority of hours of special education and related services in the Regular Early Childhood Program (and the child attends a Regular Early Childhood Program less than 10 hours per week).

Row B2. The child is receiving the majority of hours of special education and related services in some other location (and the child attends a Regular Early Childhood Program less than 10 hours per week).

If you report that a child attends a Special Education Program, you must also select the category (in column 2) that best represents the specific type of special education program that the child attends. These programs include:

Row C1. 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 C2. 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 C3. 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.)

If you report that a child attends neither a Regular Early Childhood Program nor a Special Education Program, you must select the category (in column 2) that best represents the specific environment in which the child receives the majority of hours of special education and related services. These environments include:

Row D1. Home. Unduplicated total who received special education and related services in the principal residence of the child's family or caregivers, and who attended neither a Regular Early Childhood Program nor 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 or some other location that is not in any other category (row D2). The term caregiver includes babysitters.

Row D2. Service provider location or Some Other location that is not in any other category. Unduplicated total who received all of their special education and related services from a service provider or some other location that is not in any other category, and who attended neither a Regular Early Childhood Program nor 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, and

• hospital facilities on an outpatient basis.

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.

Sections C and E. Educational Environments of Children with Disabilities by Race/Ethnicity

In October 2007, the Department of Education published its Final Guidance on Maintaining, Collecting and Reporting Racial and Ethnic Data to the U.S. Department of Education in the Federal Register (Vol. 72, No. 202, available at http://www.gpoaccess.gov/nara/index.html ), referred to in these instructions as the new guidance. The procedures for collecting, aggregating, and reporting race and ethnicity, as described in the new guidance, must be implemented by no later than the report of the 2010 Educational Environments data. When implementing the new reporting guidance, SEAs must do so at the beginning of the relevant reporting period and must apply the guidance consistently to ALL data reported within that period.

DO NOT USE THIS form to report race/ethnicity within the five categories as applied in previous years.⁴ To report Educational Environments under the five race/ethnicity categories, you must use Table 3 – RE5 (5 race/ethnicity reporting categories as used prior to 2007 guidance).

SEAs who have fully implemented the Department of Education’s new guidance (10/07) should report all children with disabilities according to the seven categories listed below. The following definitions of the seven categories for aggregate report of race/ethnicity have been adapted from definitions appearing in the new guidance.

Hispanic/Latino	A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. Refers to Hispanic and/or Latino.
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. (Does not include persons of Hispanic/Latino ethnicity.)
Asian	A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent. This includes, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. (Does not include persons of Hispanic/Latino ethnicity.)
Black or African American	A person having origins in any of the Black racial groups of Africa. (Does not include persons of Hispanic/Latino ethnicity.)
Native Hawaiian or Other Pacific Islander	A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or the Pacific Islands. (Does not include persons of Hispanic/Latino ethnicity.)
White	A person having origins in any of the original peoples of Europe, the Middle East, or North Africa. (Does not include persons of Hispanic/Latino ethnicity.)
Two or more races	A person having origins in two or more of the five race categories listed immediately above. (Does not include persons of Hispanic/Latino ethnicity.)
Total	The unduplicated total across the seven (7) race/ethnicity designations.

Note that each child should be reported in only one of the race/ethnicity categories, above.

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.

Use the educational environment categories defined in the instructions in Section A to report children with disabilities ages 3-5. Use the race/ethnicity categories and procedures described for Sections C and G, above.

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.⁵ 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. Use the race/ethnicity categories and procedures described for Sections C and G, above.

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: XX/XX/XXXX

2010

STATE: ____________________

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

EDUCATIONAL ENVIRONMENT: COLUMN 1 COLUMN 2		AGE
		3	4	5	TOTAL
Row Set (A) CHILDREN ATTENDING A REGULAR EARLY CHILDHOOD PROGRAM AT LEAST 10 HRS PER WEEK, …	(A1) …and RECEIVING the majority of hours of SPECIAL EDUCATION and related SERVICES in the REGULAR EARLY CHILDHOOD PROGRAM
	(A2) …and RECEIVING the majority of hours of SPECIAL EDUCATION and related SERVICES in some OTHER LOCATION
Row Set (B) CHILDREN ATTENDING A REGULAR EARLY CHILDHOOD PROGRAM LESS THAN 10 HRS PER WEEK, …	(B1) …and RECEIVING the majority of hours of SPECIAL EDUCATION and related SERVICES in the REGULAR EARLY CHILDHOOD PROGRAM
	(B2) …and RECEIVING the majority of hours of SPECIAL EDUCATION and related SERVICES in some OTHER LOCATION
Row Set (C) CHILDREN ATTENDING A SPECIAL EDUCATION PROGRAM (NOT in any regular early childhood program), …	(C1) …specifically, a SEPARATE SPECIAL EDUCATION CLASS
	(C2) …specifically, a SEPARATE SCHOOL
	(C3) …specifically, a RESIDENTIAL FACILITY
Row Set (D) CHILDREN ATTENDING NEITHER A REGULAR EARLY CHILDHOOD PROGRAM NOR A SPECIAL EDUCATION PROGRAM (NOT INCLUDED IN ROW SETS A, B, OR C)	(D1) …and RECEIVING the majority of hours of SPECIAL EDUCATION and related SERVICES at HOME
	(D2) …and RECEIVING the majority of hours of SPECIAL EDUCATION and related SERVICES at the SERVICE PROVIDER LOCATION or some OTHER LOCATION not in any other category
TOTAL (OF ROWS A1 – D2)

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: XX/XX/XXXX

2010

STATE: ____________________

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

DISABILITY		CHILDREN ATTENDING A REGULAR EARLY CHILDHOOD PROGRAM
		(A) AT LEAST 10 HOURS PER WEEK				(B) LESS THAN 10 HOURS PER WEEKS
		(A1) RECEIVING MAJORITY OF HOURS OF SERVICES IN REGULAR EC PROGRAM		(A2) RECEIVING MAJORITY OF HOURS OF SERVICES IN SOME OTHER LOCATION		(B1) RECEIVING MAJORITY OF HOURS OF SERVICES IN REGULAR EC PROGRAM		(B2) RECEIVING MAJORITY OF HOURS OF SERVICES IN SOME OTHER 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 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: XX/XX/XXXX

2010

STATE: ____________________

SECTION B (CONTINUED)

DISABILITY	(C) CHILDREN ATTENDING A SPECIAL EDUCATION PROGRAM (NOT IN ANY REGULAR EARLY CHILDHOOD PROGRAM)			(D) CHILDREN ATTENDING NEITHER A REGULAR EARLY CHILDHOOD PROGRAM NOR A SPECIAL EDUCATION PROGRAM
	(C1) SEPARATE CLASS	(C2) SEPARATE SCHOOL	(C3) RESIDENTIAL FACILITY	(D1) RECEIVING MAJORITY OF HOURS OF SERVICES IN HOME	(D2) RECEIVING MAJORITY OF HOURS OF SERVICES IN SERVICE PROVIDER LOCATION OR SOME OTHER 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: XX/XX/XXXX

2010

STATE: ____________________

SECTION B (CONTINUED)

DISABILITY		CHILDREN ATTENDING A REGULAR EARLY CHILDHOOD PROGRAM (PERCENT)
		(A) AT LEAST 10 HOURS PER WEEK (PERCENT)				(B) LESS THAN 10 HOURS PER WEEKS (PERCENT)
		(A1) RECEIVING MAJORITY OF HOURS OF SERVICES IN REGULAR EC PROGRAM		(A2) RECEIVING MAJORITY OF HOURS OF SERVICES IN SOME OTHER LOCATION		(B1) RECEIVING MAJORITY OF HOURS OF SERVICES IN REGULAR EC PROGRAM		(B2) RECEIVING MAJORITY OF HOURS OF SERVICES IN SOME OTHER 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 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: XX/XX/XXXX

2010

STATE: ____________________

SECTION B (continued)

DISABILITY	(C) CHILDREN ATTENDING A SPECIAL EDUCATION PROGRAM (NOT IN ANY REGULAR EARLY CHILDHOOD PROGRAM) (PERCENT)1			(D) CHILDREN ATTENDING NEITHER A REGULAR EARLY CHILDHOOD PROGRAM NOR A SPECIAL EDUCATION PROGRAM
	(C1) SEPARATE CLASS (PERCENT)	(C2) SEPARATE SCHOOL (PERCENT)	(C3) RESIDENTIAL FACILITY (PERCENT)	(D1) RECEIVING MAJORITY OF HOURS OF SERVICES IN HOME (PERCENT)	(D2) RECEIVING MAJORITY OF HOURS OF SERVICES IN SERVICE PROVIDER LOCATION OR SOME OTHER 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 DELAY1
TOTAL:

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: XX/XX/XXXX

2010 STATE: ____________________

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

EDUCATIONAL ENVIRONMENT:		RACE/ETHNICITY
		HISPANIC/ LATINO	AMERICAN INDIAN OR ALASKA NATIVE	ASIAN	BLACK OR AFRICAN AMERICAN	NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER	WHITE	TWO OR MORE RACES	TOTAL
Row Set (A) CHILDREN ATTENDING A REGULAR EARLY CHILDHOOD PROGRAM AT LEAST 10 HRS PER WEEK, …	(A1)…and RECEIVING the majority of hours of SPECIAL EDUCATION AND RELATED SERVICES in the REGULAR EARLY CHILDHOOD PROGRAM
	(A2)…and RECEVING the majority of hours of SPECIAL EDUCATION AND RELATED SERVICES in some OTHER LOCATION
Row Set (B) CHILDREN ATTENDING A REGULAR EARLY CHILDHOOD PROGRAM AT LEAST 10 HRS PER WEEK, …	(B1)…and RECEIVING the majority of hours of SPECIAL EDUCATION AND RELATED SERVICES in the REGULAR EARLY CHILDHOOD PROGRAM
	(B2)…and RECEVING the majority of hours of SPECIAL EDUCATION AND RELATED SERVICES in some OTHER LOCATION
Row Set (C) CHILDREN ATTENDING A SPECIAL EDUCATION PROGRAM (NOT in any regular early childhood program), …	(C1)…specifically, a SEPARATE SPECIAL EDUCATION CLASS
	(C2)…specifically, a SEPARATE SCHOOL
	(C3)…specifically, a RESIDENTIAL FACILITY
Row Set (D) CHILDREN ATTENDING NEITHER A REGULAR EARLY CHILDHOOD PROGRAM NOR A SPECIAL EDUCATION PROGRAM (NOT INCLUDED IN ROW SETS A, B, OR C)	(D1)… and RECEIVING the majority of hours of SPECIAL EDUCATION and related SERVICES at HOME
	(D2)…and RECEIVING the majority of hours of SPECIAL EDUCATION and related SERVICES at the SERVICE PROVIDER LOCATION or some OTHER LOCATION not in any other category
(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: XX/XX/XXXX

2010 STATE: ____________________

SECTION C (CONTINUED)

EDUCATIONAL ENVIRONMENT:		RACE/ETHNICITY (PERCENT)1
		HISPANIC/ LATINO	AMERICAN INDIAN OR ALASKA NATIVE	ASIAN	BLACK OR AFRICAN AMERICAN	NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER	WHITE	TWO OR MORE RACES	TOTAL
Row Set (A) CHILDREN ATTENDING A REGULAR EARLY CHILDHOOD PROGRAM AT LEAST 10 HRS PER WEEK, …	(A1)…and RECEIVING the majority of hours of SPECIAL EDUCATION AND RELATED SERVICES in the REGULAR EARLY CHILDHOOD PROGRAM
	(A2)…and RECEVING the majority of hours of SPECIAL EDUCATION AND RELATED SERVICES in some OTHER LOCATION
Row Set (B) CHILDREN ATTENDING A REGULAR EARLY CHILDHOOD PROGRAM AT LEAST 10 HRS PER WEEK, …	(B1)…and RECEIVING the majority of hours of SPECIAL EDUCATION AND RELATED SERVICES in the REGULAR EARLY CHILDHOOD PROGRAM
	(B2)…and RECEVING the majority of hours of SPECIAL EDUCATION AND RELATED SERVICES in some OTHER LOCATION
Row Set (C) CHILDREN ATTENDING A SPECIAL EDUCATION PROGRAM (NOT in any regular early childhood program), …	(C1)…specifically, a SEPARATE SPECIAL EDUCATION CLASS
	(C2)…specifically, a SEPARATE SCHOOL
	(C3)…specifically, a RESIDENTIAL FACILITY
Row Set (D) CHILDREN ATTENDING NEITHER A REGULAR EARLY CHILDHOOD PROGRAM NOR A SPECIAL EDUCATION PROGRAM (NOT INCLUDED IN ROW SETS A, B, OR C)	(D1)… and RECEIVING the majority of hours of SPECIAL EDUCATION and related SERVICES at HOME
	(D2)…and RECEIVING the majority of hours of SPECIAL EDUCATION and related SERVICES at the SERVICE PROVIDER LOCATION or some OTHER LOCATION not in any other category
(C) TOTAL (OF ROWS A1 – B5)

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: XX/XX/XXXX

2010

STATE: ____________________

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

EDUCATIONAL ENVIRONMENT:		GENDER
		MALE	FEMALE	TOTAL
Row Set (A) CHILDREN ATTENDING A REGULAR EARLY CHILDHOOD PROGRAM AT LEAST 10 HRS PER WEEK, …	(A1)…and RECEIVING the majority of hours of SPECIAL EDUCATION AND RELATED SERVICES in the REGULAR EARLY CHILDHOOD PROGRAM
	(A2)…and RECEVING the majority of hours of SPECIAL EDUCATION AND RELATED SERVICES in some OTHER LOCATION
Row Set (B) CHILDREN ATTENDING A REGULAR EARLY CHILDHOOD PROGRAM AT LEAST 10 HRS PER WEEK, …	(B1)…and RECEIVING the majority of hours of SPECIAL EDUCATION AND RELATED SERVICES in the REGULAR EARLY CHILDHOOD PROGRAM
	(B2)…and RECEVING the majority of hours of SPECIAL EDUCATION AND RELATED SERVICES in some OTHER LOCATION
Row Set (C) CHILDREN ATTENDING A SPECIAL EDUCATION PROGRAM (NOT in any regular early childhood program), …	(C1)…specifically, a SEPARATE SPECIAL EDUCATION CLASS
	(C2)…specifically, a SEPARATE SCHOOL
	(C3)…specifically, a RESIDENTIAL FACILITY
Row Set (D) CHILDREN ATTENDING NEITHER A REGULAR EARLY CHILDHOOD PROGRAM NOR A SPECIAL EDUCATION PROGRAM (NOT INCLUDED IN ROW SETS A, B, OR C)	(D1)… and RECEIVING the majority of hours of SPECIAL EDUCATION and related SERVICES at HOME
	(D2)…and RECEIVING the majority of hours of SPECIAL EDUCATION and related SERVICES at the SERVICE PROVIDER LOCATION or some OTHER LOCATION not in any other category
(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: XX/XX/XXXX

2010

STATE: ____________________

SECTION D (CONTINUED)

EDUCATIONAL ENVIRONMENT:		GENDER (PERCENT)1
		MALE	FEMALE	TOTAL
Row Set (A) CHILDREN ATTENDING A REGULAR EARLY CHILDHOOD PROGRAM AT LEAST 10 HRS PER WEEK, …	(A1)…and RECEIVING the majority of hours of SPECIAL EDUCATION AND RELATED SERVICES in the REGULAR EARLY CHILDHOOD PROGRAM
	(A2)…and RECEVING the majority of hours of SPECIAL EDUCATION AND RELATED SERVICES in some OTHER LOCATION
Row Set (B) CHILDREN ATTENDING A REGULAR EARLY CHILDHOOD PROGRAM AT LEAST 10 HRS PER WEEK, …	(B1)…and RECEIVING the majority of hours of SPECIAL EDUCATION AND RELATED SERVICES in the REGULAR EARLY CHILDHOOD PROGRAM
	(B2)…and RECEVING the majority of hours of SPECIAL EDUCATION AND RELATED SERVICES in some OTHER LOCATION
Row Set (C) CHILDREN ATTENDING A SPECIAL EDUCATION PROGRAM (NOT in any regular early childhood program), …	(C1)…specifically, a SEPARATE SPECIAL EDUCATION CLASS
	(C2)…specifically, a SEPARATE SCHOOL
	(C3)…specifically, a RESIDENTIAL FACILITY
Row Set (D) CHILDREN ATTENDING NEITHER A REGULAR EARLY CHILDHOOD PROGRAM NOR A SPECIAL EDUCATION PROGRAM (NOT INCLUDED IN ROW SETS A, B, OR C)	(D1)… and RECEIVING the majority of hours of SPECIAL EDUCATION and related SERVICES at HOME
	(D2)…and RECEIVING the majority of hours of SPECIAL EDUCATION and related SERVICES at the SERVICE PROVIDER LOCATION or some OTHER LOCATION not in any other category
(C) TOTAL (OF ROWS A1 – B5)

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: XX/XX/XXXX

2010

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
Row Set (A) CHILDREN ATTENDING A REGULAR EARLY CHILDHOOD PROGRAM AT LEAST 10 HRS PER WEEK, …	(A1)…and RECEIVING the majority of hours of SPECIAL EDUCATION AND RELATED SERVICES in the REGULAR EARLY CHILDHOOD PROGRAM
	(A2)…and RECEVING the majority of hours of SPECIAL EDUCATION AND RELATED SERVICES in some OTHER LOCATION
Row Set (B) CHILDREN ATTENDING A REGULAR EARLY CHILDHOOD PROGRAM AT LEAST 10 HRS PER WEEK, …	(B1)…and RECEIVING the majority of hours of SPECIAL EDUCATION AND RELATED SERVICES in the REGULAR EARLY CHILDHOOD PROGRAM
	(B2)…and RECEVING the majority of hours of SPECIAL EDUCATION AND RELATED SERVICES in some OTHER LOCATION
Row Set (C) CHILDREN ATTENDING A SPECIAL EDUCATION PROGRAM (NOT in any regular early childhood program), …	(C1)…specifically, a SEPARATE SPECIAL EDUCATION CLASS
	(C2)…specifically, a SEPARATE SCHOOL
	(C3)…specifically, a RESIDENTIAL FACILITY
Row Set (D) CHILDREN ATTENDING NEITHER A REGULAR EARLY CHILDHOOD PROGRAM NOR A SPECIAL EDUCATION PROGRAM (NOT INCLUDED IN ROW SETS A, B, OR C)	(D1)… and RECEIVING the majority of hours of SPECIAL EDUCATION and related SERVICES at HOME
	(D2)…and RECEIVING the majority of hours of SPECIAL EDUCATION and related SERVICES at the SERVICE PROVIDER LOCATION or some OTHER LOCATION not in any other category
(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: XX/XX/XXXX

2010

STATE: ____________________

SECTION E (CONTINUED)

EDUCATIONAL ENVIRONMENT:		LIMITED ENGLISH PROFICIENCY STATUS (PERCENT)1
		YES	NO	TOTAL
Row Set (A) CHILDREN ATTENDING A REGULAR EARLY CHILDHOOD PROGRAM AT LEAST 10 HRS PER WEEK, …	(A1)…and RECEIVING the majority of hours of SPECIAL EDUCATION AND RELATED SERVICES in the REGULAR EARLY CHILDHOOD PROGRAM
	(A2)…and RECEVING the majority of hours of SPECIAL EDUCATION AND RELATED SERVICES in some OTHER LOCATION
Row Set (B) CHILDREN ATTENDING A REGULAR EARLY CHILDHOOD PROGRAM AT LEAST 10 HRS PER WEEK, …	(B1)…and RECEIVING the majority of hours of SPECIAL EDUCATION AND RELATED SERVICES in the REGULAR EARLY CHILDHOOD PROGRAM
	(B2)…and RECEVING the majority of hours of SPECIAL EDUCATION AND RELATED SERVICES in some OTHER LOCATION
Row Set (C) CHILDREN ATTENDING A SPECIAL EDUCATION PROGRAM (NOT in any regular early childhood program), …	(C1)…specifically, a SEPARATE SPECIAL EDUCATION CLASS
	(C2)…specifically, a SEPARATE SCHOOL
	(C3)…specifically, a RESIDENTIAL FACILITY
Row Set (D) CHILDREN ATTENDING NEITHER A REGULAR EARLY CHILDHOOD PROGRAM NOR A SPECIAL EDUCATION PROGRAM (NOT INCLUDED IN ROW SETS A, B, OR C)	(D1)… and RECEIVING the majority of hours of SPECIAL EDUCATION and related SERVICES at HOME
	(D2)…and RECEIVING the majority of hours of SPECIAL EDUCATION and related SERVICES at the SERVICE PROVIDER LOCATION or some OTHER LOCATION not in any other category
(C) TOTAL (OF ROWS A1 – B5)

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: XX/XX/XXXX

2010

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: XX/XX/XXXX

2010

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: XX/XX/XXXX

2010

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: XX/XX/XXXX

2010

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: XX/XX/XXXX

2010

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 SCHOOL (PERCENT)	(E) RESIDENTIAL FACILITY (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: XX/XX/XXXX

2010

STATE: ____________________

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

EDUCATIONAL ENVIRONMENT	RACE/ETHNICITY
	HISPANIC/ LATINO	AMERICAN INDIAN OR ALASKA NATIVE	ASIAN	BLACK OR AFRICAN AMERICAN	NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER	WHITE	TWO OR MORE RACES	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: XX/XX/XXXX

2010

STATE: ____________________

SECTION G (CONTINUED)

EDUCATIONAL ENVIRONMENT	RACE/ETHNICITY (PERCENT)1
	HISPANIC/ LATINO (PERCENT)	AMERICAN INDIAN OR ALASKA NATIVE (PERCENT)	ASIAN (PERCENT)	BLACK OR AFRICAN AMERICAN (PERCENT)	NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER (PERCENT)	WHITE (PERCENT)	TWO OR MORE RACES (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 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: XX/XX/XXXX

2010

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: XX/XX/XXXX

2010

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: XX/XX/XXXX

2010

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: XX/XX/XXXX

2010

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.

2 OSEP recognizes that, rather than referencing a numerical date (such as November 1) for taking its Child Count each year, some States may have identified a specific day of the week in a given month each year (such as the last Friday of each October). In addition, some States may be unable to reference the same Child Count date if, in a given year, that date falls on a weekend. Therefore, it is acceptable for the actual date of the Child Count in any given year to slide within six (6) days of the State-established reference date without generating any error flags upon submission to the Federal data system.

3 Include children with disabilities enrolled by their parents in a private elementary school and receiving special education and related services in accordance with a services plan. The private elementary school must be a nonprofit institutional day or residential school, including a public elementary charter school, that provides elementary education, as determined under State law.

4 If your State is collecting race/ethnicity information in a manner that is NOT in full accordance with the new guidance (including the two-part question format for ascertaining and reporting Hispanic ethnicity), you should report aggregate data through the 5-category format ( the ‘…-RE5’ version of the form for this collection) until your State is prepared to fully implement the new guidance, and then to do so for all of the IDEA Part B collections associated with the given reporting reference year (e.g., 2010-11 year). Until you make that full transition, you should use the –RE5 version of this form and apply either of two options to account for students who are identified as multiracial or two or more races, as described in the document entitled, “Handling Missing Data When Reporting Race/Ethnicity” (https://www.ideadata.org/docs/PartBRaceEthnicity.doc).

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