Form PHC-10 "Application to the Commissioner of Education for Approval for an Evaluation to Attend a 4201 State-Supported School" - New York

What Is Form PHC-10?

This is a legal form that was released by the New York State Education Department - a government authority operating within New York. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2020;
  • The latest edition provided by the New York State Education Department;
  • Easy to use and ready to print;
  • Available in Spanish;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form PHC-10 by clicking the link below or browse more documents and templates provided by the New York State Education Department.

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Download Form PHC-10 "Application to the Commissioner of Education for Approval for an Evaluation to Attend a 4201 State-Supported School" - New York

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THE STATE EDUCATION DEPARTMENT / THE UNIVERSITY OF THE STATE OF NEW YORK / ALBANY, NY 12234
OFFICE OF SPECIAL EDUCATION
SPECIAL EDUCATION QUALITY ASSURANCE
NONDISTRICT UNIT
89 Washington Avenue, Room 309 EB  Albany, NY 12234
1 Park Place, 3
rd
Floor, Peekskill, NY 10566
Telephone (518) 473-1185 Fax: (518) 473-5769
Telephone (914) 940-2900 Fax: (914) 402-2180
www.p12.nysed.gov/specialed
PHC-10 APPLICATION TO THE COMMISSIONER OF EDUCATION
FOR APPROVAL FOR AN EVALUATION TO ATTEND A 4201
STATE-SUPPORTED SCHOOL
INSTRUCTIONS
Please PRINT or TYPE the information on this application.
The appropriate examination(s) as listed below, administered within the last 12 months, must be
submitted with this form to determine the student's eligibility.
Categories of Disability
Examination(s) Required
Deafness
Audiogram
Functional Deafness
Audiogram
Blindness
Ophthalmological examination
Orthopedic Impairment
Medical/therapy reports
Emotional Disturbance
Psychological and/or psychiatric examination
Deaf-Blindness
Audiogram and Ophthalmological examination
Note: During the processing of this application, it is necessary that your child remain in his or her
current placement to ensure the continuity of his/her education program.
For further assistance in completing this application, please contact the Office listed above.
F
Child's Name:
DOB:
M
(Last)
(First)
Parents'/Guardians' Names:
Address:
(Street)
(City)
(State)
(Zip Code)
County of Location:
Telephone Number:
Local School District of Residence:
Contact Person: _____________________________________________________________________________
Address:
(Street)
(City)
(State)
(Zip Code)
Fax
Telephone Number:
Number:
Indicate the dominant language used in the home:
Is the child a resident of New York State?
Yes
No
If no, explain:
September 2020
THE STATE EDUCATION DEPARTMENT / THE UNIVERSITY OF THE STATE OF NEW YORK / ALBANY, NY 12234
OFFICE OF SPECIAL EDUCATION
SPECIAL EDUCATION QUALITY ASSURANCE
NONDISTRICT UNIT
89 Washington Avenue, Room 309 EB  Albany, NY 12234
1 Park Place, 3
rd
Floor, Peekskill, NY 10566
Telephone (518) 473-1185 Fax: (518) 473-5769
Telephone (914) 940-2900 Fax: (914) 402-2180
www.p12.nysed.gov/specialed
PHC-10 APPLICATION TO THE COMMISSIONER OF EDUCATION
FOR APPROVAL FOR AN EVALUATION TO ATTEND A 4201
STATE-SUPPORTED SCHOOL
INSTRUCTIONS
Please PRINT or TYPE the information on this application.
The appropriate examination(s) as listed below, administered within the last 12 months, must be
submitted with this form to determine the student's eligibility.
Categories of Disability
Examination(s) Required
Deafness
Audiogram
Functional Deafness
Audiogram
Blindness
Ophthalmological examination
Orthopedic Impairment
Medical/therapy reports
Emotional Disturbance
Psychological and/or psychiatric examination
Deaf-Blindness
Audiogram and Ophthalmological examination
Note: During the processing of this application, it is necessary that your child remain in his or her
current placement to ensure the continuity of his/her education program.
For further assistance in completing this application, please contact the Office listed above.
F
Child's Name:
DOB:
M
(Last)
(First)
Parents'/Guardians' Names:
Address:
(Street)
(City)
(State)
(Zip Code)
County of Location:
Telephone Number:
Local School District of Residence:
Contact Person: _____________________________________________________________________________
Address:
(Street)
(City)
(State)
(Zip Code)
Fax
Telephone Number:
Number:
Indicate the dominant language used in the home:
Is the child a resident of New York State?
Yes
No
If no, explain:
September 2020
Indicate the child's primary disability (check only one):
Deafness
Visual Impairment
Functional Deafness
Orthopedic Impairment
Blindness
Emotional Disturbance
Deaf-Blindness
If the child has multiple disabilities, check all that apply:
Intellectual Disability
Hearing Impairment
Autism
Visual Impairment
Emotional Disturbance
Orthopedic Impairment
Speech or Language Impairment
Other Health Impairment
Deafness
Traumatic Brain Injury
Indicate the current educational placement of the child:
School Name:
Telephone Number:
Program Administrator:
Address:
(Street)
(City)
(State)
(Zip Code)
Person Completing this Application
Name:
Title:
Phone Number:
Date
Signature of Parent or Guardian
SED USE ONLY
Dear Parent(s):
Your child has been recommended and approved for an evaluation at the 4201 State-supported
school indicated below. This office has approved this evaluation to be conducted for your child at the
State-supported school effective as of the date of this approval. It will be necessary for you to contact
the State-supported school indicated below to make the necessary arrangements so that your child may
be evaluated promptly. The results of this evaluation will be forwarded to your school district Committee
on Special Education/Committee on Preschool Special Education for its review. If you have any
questions, please contact this office at 518-473-1185.
Sincerely,
Signature of Representative
Date
c:
CSE
CPSE
NYC CBST
4201 School:
September 2020
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