APPLICATION FOR APPROVAL OF PRIVATE RESIDENTIAL PLACEMENT ROOM AND BOARD REIMBURSEMENT - Form 34-37 Instructions - Complete and submit prior to placement

Oct 10, 2026

Uploaded by Kyle

Application form for special education approval of private residential placement room and board reimbursement. Used when a school district determines at an IEP meeting that the least restrictive environment is a private residential placement. Submission timing is required prior to placement, renewal, or changes, and reimbursement approval depends on receiving all required documentation. Includes Section I identification fields, contact and facility information, disability key codes, and out-of-state placement questions, plus Section II placement history and educational environment codes.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages6

Reading Time15 min

AccessFree to download

Instructions

Out-of-State Placement Questions

Section I: Identification

Disability Key

Section II: Placement Information

History of Services Provided

Educational Environment Codes and Brief Descriptions

APPLICATION FOR APPROVAL OF PRIVATE RESIDENTIAL PLACEMENT ROOM AND BOARD REIMBURSEMENT 100 North First Street, N-253 Springfield, Illinois 62777-0001 SPECIAL EDUCATION DEPARTMENT FORM 34-37 INSTRUCTIONS: This form is to be completed when a school district determines at an Individualized Education Program (IEP) meeting that the least restrictive environment for a student is a private residential placement. It must be submitted in a timely manner to allow approval prior to the district effecting the placement. Please note: No room and board reimbursement is available for students who are 22 years old or older. Complete and submit one copy of this application form PRIOR to placement, renewal due date, or change of placement. Applications may be submitted in sections. However, reimbursement will not be approved until all required documentation has been received. Application should be submitted [to](to 3437RnB@isbe.net)[ ](to 3437RnB@isbe.net)[3437RnB@isbe.net](to 3437RnB@isbe.net). Check one: Initial Placement – Anticipated Start Date: Continuing Placement Change of District or Facility Code | SECTION I: IDENTIFICATION (Items must match the information listed in I-Star.) | | | | | | | --- | --- | --- | --- | --- | --- | | NAME OF STUDENT (LAST NAME / FIRST NAME-Do not use nicknames.)
Rose, David | | | | STUDENT INFORMATION SYSTEM NUMBER
123456789 | | | GENDER
■ Male Female Non-Binary | BIRTH DATE (MM/DD/YY)
07/02/2008 | | | REGION-COUNTY-DISTRICT-TYPE CODE
12-345-6789-01-2345 | | | RESIDENT DISTRICT NAME AND NUMBER AND ADDRESS (Street, City, ZIP Code)
Springfield District 186 3063 Fiat Ave, Springfield 62703 | | | | | | | NAME AND TITLE OF CONTACT PERSON FOR DISTRICT/CO-OP
Ted Mullens, Assistant Director | | | TELEPHONE NUMBER (Include Area Code)
217-555-5555 | | EMAIL
[jrose@springfield.org](jrose@springfield.org) | | RESIDENTIAL or COMBINATION PRIVATE FACILITY CODE (Where student is located)
68289 | | RESIDENTIAL PRIVATE FACILITY NAME AND ADDRESS (Street, City, ZIP Code)
NeuroRestorative Willow House 2500 Walnut Bldg A Carbondale 62901 | | | | | Complete the section below if the Residential Private Facility code is a Residential Only code. | | | | | | | TUITION PRIVATE FACILITY CODE
14527 | | TUITION PRIVATE FACILITY NAME AND ADDRESS (Street, City, ZIP Code)
NeuroRestorative Carbondale Academy 300 W Mill St. 62901 | | | | | | | | | | DISABILITY KEY | | | | | | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | A | = | Intellectual Disability | F | = | Hearing Impairment | K | = | Emotional Disability | O | = | Autism | | C | = | Orthopedic Impairment | G | = | Deafness | L | = | Other Health Impairment | P | = | Traumatic Brain Injury | | D | = | Specific Learning Disability | H | = | Deaf-Blindness | M | = | Multiple Disabilities | | | | |
E
| = | Visual Impairment | I | = | Speech and/or Language Impairment | N | = | Developmental Delay | | | | For Initial Out-of-State Applications: Has an Illinois Department of Children and Family Services (DCFS) Interstate Compact been initiated if the student is under the age of 18? For information about an Interstate Compact, [please contact DCFS at](please contact DCFS at DCFS.InterstateCompactGeneral@illinois.gov)[ ](please contact DCFS at DCFS.InterstateCompactGeneral@illinois.gov)[DCFS.InterstateCompactGeneral@illinois.gov](please contact DCFS at DCFS.InterstateCompactGeneral@illinois.gov). Yes No Initial or Continuing Out-of-State Placement for all students: Complete the following. Yes N/A Prior to the placement of a child in an out-of-state special education residential facility: Did the school district inform the child and/or the parent/guardian of the option to place the child in a special education residential facility located within this state , if any, that provides treatment and services comparable to those provided by the out-o

FAQs

When is Form 34-37 required for a student’s private residential placement?

Use the form when an IEP meeting determines the least restrictive environment is a private residential placement. Submit it in a timely manner for approval before the district effects the placement.

Is room and board reimbursement available for all students?

No reimbursement is available for students who are 22 years old or older.

What information must be completed regarding disability and educational environment codes?

Section I collects the student’s disability key, and Section II requires a two-year placement history with the primary disability code and educational environment (EE) code, including beginning and discontinued dates for each setting.

Oct 10, 2026

Uploaded by Kyle