Request for Special Education Contract Approval (EF-S-03) Instructions

General Instructions

The EF-S-03 Request for Special Education Contract Approval is to be used for reporting all contracts between school administrative units (SAUs) and agencies/providers of special education services. Required data include: service code from the table below, provider name, social security number, license number (if applicable), certification number (if applicable), Criminal History Record Check (CHRC) expiration date and a yes or not to indicate whether federal funds were used for that specific service. Also, please indicate the name of the SAU, the name of the person completing the form and the telephone number of that individual. If this is the original EF-S-03 submission, please indicate by checking off the "Original Report" checkbox in the upper left corner.

Page Numbering

If more than one page is necessary, please insert additional lines or copy the original, number sequentially and indicate the total number of pages (e.g., page 1 of 2).

Amendments

If the SAU develops a contract for services after submission of the original EF-S-03, an amended EF-S-03 must be submitted. Please provide all appropriate information and check off the "Amended Report" checkbox in the upper left corner.

Do not submit individual contracts to the Office of Special Services.

These must be maintained at the SAU level. Copies sent to the Department will be returned to the SAU.

Specific Instructions

Service code (column 1)
Please see table below for applicable service codes.

Note: school psychological service providers with 093 certificates will have a service code of 09.

Note: when using a code 29, please explain the type of service to be provided by the provider.

Code

Contracted Service

09

School psychologist/neuro-psychological aides/certificate 093/licensed clinical professional counselors

11

Speech-Language pathologist

13

Audiologist

14

Occupational therapist/aide

16

Physical therapist/aide

18

Social worker

19

Teacher of the deaf

20

Special education consultant

21

Attorney—local funds ONLY

28

Sign language interpreter/translator

29

Other, explanation of services required

31

Cued speech transliterator

32

Behavior specialist

Provider (column 2)
Please use a last name, first name format. You must identify the name of the actual provider, not the name of the agency in this column.

Social security number (column 3)
Enter the social security number of the provider, not the federal tax ID number. This is required information.

License number and expiration date (column 4 and 5)
Enter the license number and expiration date for each provider, if applicable.

Certification number and expiration date (column 6 and 7)
Enter the certificate number/type and expiration date for each provider, if applicable.

CHRC expiration date (column 8)
Enter the expiration date of the CHRC for each provider.

The Office of Special Services will verify certification and licensure for each individual listed on the EF-S-03 and will notify SAUs of any problems with service providers. Each person subject to the fingerprinting requirement in accordance with Title 20-A § 6103(4-a) and 4-b), and § 13011 must provide a valid CHRC approval issued by the Department of Education.

Federal funds (column 9)
Please indicate yes or no as to whether your SAU uses federal funds to pay for this service. Maine Special Education Regulations (MUSER), Chapter 101, XVIII.1.C specifies positions that can be included for state subsidy. Medical evaluations for diagnostic purposes only, must be funded with federal funds and cannot be considered for state subsidy. Any medical evaluations provided which are coded 29 must be specified as evaluations and marked yes.

A copy of the approved EF-S-03 will be mailed to the Director of Special Education upon verification.

If you have any questions regarding the EF-S-03, please call Sheryl Banden at 207-624-6658 or sheryl.banden@maine.gov.