APPLICATION FOR APPROVAL OF PRIVATE RESIDENTIAL PLACEMENT ROOM AND BOARD REIMBURSEMENT

Oct 10, 2026

Uploaded by Mia

Application instructions and form text for requesting approval of private residential placement room and board reimbursement under a student’s IEP determination. It explains submission timing prior to placement or changes, limits for students age 22+, and notes reimbursement approval depends on receipt of all required documentation. The form collects student identification, district and facility details, contact information, disability codes, and placement history within the last two school years, including educational environment (EE) codes and out-of-state compliance questions.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages6

Reading Time15 min

AccessFree to download

SECTION I: IDENTIFICATION

Disability Key

SECTION II: PLACEMENT INFORMATION

History of Services Provided

Educational Environment Codes and Brief Description Key

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.) | | | | STUDENT INFORMATION SYSTEM NUMBER | | | GENDER
Male Female Non-Binary | BIRTH DATE (MM/DD/YY) | | | REGION-COUNTY-DISTRICT-TYPE CODE | | | RESIDENT DISTRICT NAME AND NUMBER AND ADDRESS (Street, City, ZIP Code) | | | | | | | NAME AND TITLE OF CONTACT PERSON FOR DISTRICT/CO-OP | | | TELEPHONE NUMBER (Include Area Code) | | EMAIL | | RESIDENTIAL or COMBINATION PRIVATE FACILITY CODE (Where student is located) | | RESIDENTIAL PRIVATE FACILITY NAME AND ADDRESS (Street, City, ZIP Code) | | | | | Complete the section below if the Residential Private Facility code is a Residential Only code. | | | | | | | TUITION PRIVATE FACILITY CODE | | TUITION PRIVATE FACILITY NAME AND ADDRESS (Street, City, ZIP Code) | | | | Use the codes from the key below to indicate the disability(ies) of the student. Primary Disability Secondary Disability, if identified Tertiary Disability, if identified | | | | | | 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-of-state special education residential facility? SECTION II: PLACEMENT INFORMATION HISTORY OF SERVICES PROVIDED. Use the chart below to indicate the educational setting(s) in which the stude

FAQs

When must the application be submitted for private residential placement room and board reimbursement?

Submit one copy prior to placement, renewal due date, or any change of placement, in a timely manner to allow approval before the district effects the placement.

Are room and board reimbursements available for all student ages?

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

What determines whether reimbursement will be approved?

Reimbursement will not be approved until all required documentation has been received, even if applications are submitted in sections.

Oct 10, 2026

Uploaded by Mia