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

Policy: The EFS03 Request for Special Education Contract Approval is used for reporting contracts between school administrative units (SAUs) and agencies/providers of special education services that are funded with federal, State, or local funds.  This reporting is to ensure that providers of contracted services meet the required State qualifications, and to identify the source of funding for the contracted services to confirm costs are allowable. 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 (applicable only to those providers who have direct contact with students in a school setting), and an identification of the funding source.

SAU Procedure: Go to the link http://www.maine.gov/tools/whatsnew/index.php?topic=DOE_Reporting_Forms&id=477241&v=Article
On the required form, the SAU indicates 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 EFS03 submission, the SAU indicates that by checking off the "Original Report" checkbox in the upper left corner. The form must be signed and dated by the Superintendent.  If more than one page is necessary, the SAU may insert additional lines or copy the original, number sequentially and indicate the total number of pages (e.g., page 1 of 2). If the SAU develops a contract for services after submission of the original EFS03, the SAU must submit an amended EFS03, with "Amended Report" indicated in the checkbox in the upper left corner. The amended form must also be signed and dated by the Superintendent. SAUs must maintain the individual contracts at the SAU and should not submit them to the Department’s Special Services office; any copies sent to the Department will be returned to the SAU.

Service code (column 1)
Please see table below for applicable service codes.
NOTE: Providers with Conditional Licensing should not be used routinely.

Code Contracted Service Applicable Maine DOE Certificate Applicable Licensing
09 School Psychologist/Neuro-Psychological Aides/Certificate 093/Licensed Clinical Professional Counselors 093 PE xxxx = Psychological Examiner
PS xxxx = Psychologist
LC xxxx = Clinical Social Wrkr
MC xxxx = Master Social Wrker – Conditional Clinical
11 Speech-Language Pathologist
S/L Therapy Asst. - needs (at least) Ed Tech certificate
293 SP xxx = Speech/Language Pathologist
SAS xxx = Sp. Assistant (This provider works under an assigned supervisor’s license number)
ST xxxx = Temp (fulfilling fellowship under supervision of fully licensed S/L Pathologist)
13 Audiologist AP xxxx = Audiologist
14 Occupational Therapist/Aide OT xxxx = Occupational Therapist
OA xxxx = OT Aide. (This provider works under an assigned supervisor’s license number)
16 Physical Therapist/Aide PT xxxx = Physical Therapist
PA xxxx = P/T Aide (Cert not tied to any PT license)
18 Social Worker LS = Licensed Social Wrkr
LM = Master Social Wrkr
LC xxxx = Clinical Social Worker
MC xxxx = Master Social Wrker – Cond Clinical
CC xxxx = Clinical Professional Counselor
19 Teacher of the Deaf 292
20 Special Education Consultant 079
21 Attorney - Explanation of Services Required
Prior Department approval required
28 Sign Language Interpreter/Translator CIT xxxx
LIT xxxx (with limitations)
CDT
29 Other - Explanation of services, andprior Department approval required
32 Board Certified Behavior Analyst
www.BCBA.com
National Certification (If not directly supervised at all times by a certified teacher, they much be an ED Tech III at a minimum)
33 Certified Assistive Technology Professional - AT Plus, Ed Tech III National Certification (Additionally, they must hold an Ed Tech III endorsement)
34 Certified Employment Specialist Plus, Ed Tech III ACRE certification
www.syntiro.org
35 Vocational Education Evaluator 094
36 School Nurse 524 (provided as necessary per child’s IEP) RN xxxx
LPN xxxx (but only under a licensed RN) 

Provider (column 2)
Enter in a last name, first name format. The SAU 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 (columns 4 and 5)
Enter the license number and expiration date for each provider, if applicable.

Certification Number and Expiration Date (columns 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 criminal history record check (CHRC) for only those providers who have direct contact with students in a school setting. Each person subject to the fingerprinting requirement must provide a valid CHRC approval issued by the Department of Education in accordance with Title 20-A § 6103 and § 13011.

Funding Source: Federal/State/Local (column 9)
Identify the funding source. Maine Special Education Regulations (MUSER), Chapter 101, XVIII.1.C identifies those positions that can be included for State subsidy calculations. Medical evaluations (for diagnostic purposes only) must be funded with federal funds and are not allowable for State subsidy calculations. Any medical evaluations that are coded 29 must be identified as evaluations funded with federal dollars.

Department of Education (Special Services) Procedure: Special Services staff will, upon receipt of the form, either verify certification (and CHRC, if applicable) and licensure for each individual listed on the EFS03 or notify the SAU of any problems with the listing of service providers on the form or need for additional information (to be submitted to the Department within two weeks of the notification). Once the form isverified, Special Services staff will email a copy of the approved EFS03 to the SAU’s Director of Special Services. If the additional information is not submitted, or the form cannot be verified (after consultation with, and technical assistance to, the SAU), Special Service staff will notify the SAU in writing of non-approval and the requirement that the contracted service terminate immediately.  

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