New Jersey Department of Education (NJDOE)
Office of Special Education (OSE)
Introduction to Clinic/Agency Application:
A. The approval process for clinics/agencies is to ensure that only those applicants that meet the high standards set by
OSE to provide services to students with disabilities are approved. The process will take 6 to 8 months from the
submission of the initial application to final approval.
B. Clinics or agencies with fewer than three (3) individual service providers are not eligible to seek approval and/or
maintain approval as a clinic/agency through the NJDOE.
C. If an agency is approved to provide services, the agency must have service provider(s) to provide the service and be
on staff, otherwise, the agency will no longer be approved to provide such service(s) (N.J.A.C.146A:14-5.2).
D. Credentialing and Licensing requirements for each service are located within the section marked “Required
Credentials of Service Providers” and “Relevant Regulations/Guidance” for each service.
Part One: Submission and Review of Completed Application (Minimum of 3 Months)
1. Email completed application to clinicagen[email protected]v
2. Staff from the OSE will review the application and the document will be:
• Accepted as submitted.
• Returned for revisions.
• Denied as submitted.
3. The OSE will provide a letter to the applicant with the approval status of the application.
Part Two: Memorandum of Understanding (Minimum of 2 Months)
1. When an application is determined to be in order, the Office of Special Education will notify the Office of
Student Protection (OSP).
2. The OSP will send the applicant a Memorandum of Understanding (MOU). The MOU is a required agreement
between the applicant and the NJDOE that specifies how service providers will undergo the criminal history
review process while working for that clinic/agency. The MOU permits the service providers of that clinic/agency
to work in multiple schools or school districts simultaneously as long as the service providers continuously work
for that clinic/agency.
3. The applicant must sign and notarize the MOU and return to the OSP.
4. The MOU is reviewed and approved by the Office of the Attorney General.
5. The OSP will return the completed MOU to the applicant. A Vendor Registration Form will be included with the
approved MOU. This form will include a vendor-specific code that must be used when obtaining Criminal History
Reviews (CHRs) for clinic/agency staff.
Part Three: Criminal History Reviews (6 Weeks Upon Receipt of Submission)
1. All service providers listed in the application must obtain a criminal history review (CHR) using the vendor
specific code.
2. For more information regarding the procedures for obtaining a criminal history review, go to the NJDOE Office
of Student Protection website.
3.
The applicant must ensure that a copy of each service provider’s criminal history review approval is submitted to
OSE.
Page 1 of 23
Revised August 2023
4. The applicant will be notified if any of the providers have been disqualified based on the criminal history review.
Disqualification of a service provider may affect approval of the clinic/agency application.
Part Four: Final Approval (2 Weeks from Receipt of Submission of CHRs)
1. OSE will issue a final approval letter.
2. Information for the clinic/agency will be added to the NJDOE directory and the clinic/agency may contract with
schools or school districts to provide services to eligible students.
NJDOE Clinic Application starts on the following page.
Page 2 of 23
Revised August 2023
New Jersey Department of Education (NJDOE)
Office of Special Education
Clinic/Agency Initial/Amendment Application
Which type of application are you submitting? Select one:
Initial Application
Amendment
Part 1: Contact Information
Name of Clinic/Agency:
Street Address:
City: State: Zip Code:
County:
Webs
ite:
Name of clin
ic/agency administrator/primary point of contact:
Phone, Cell Phone,
Fax Number (please indicate which type):
Email:
If another corporation/entity owns the clinic/agency, complete the following:
Name of Corporation/Entity:
CEO/Chief Administrative Officer:
Street Address:
City: State: Zip Code:
C
ounty:
Phone, Cell Phone, Fax Number (please indicate which type):
Email:
Date of Application Submission:
Page 3 of 23
Revised August 2023
Page 4 of 23
Revised August 2023
Part 2: Selection of Services
Instructions
•
•
•
•
•
•
Select the service(s) for which the applicant is seeking approval.
For each service selected, indicate the location(s) where services will be provided.
Ensure
that
providers
have
the
required credentials.
Read
the
relevant
special
education
regulations
and
requirements
for
each
service
to be
provided.
The
regulations
can be
found
in
Subchapter Five
at
N.J.A.C.6A:14.
For auxiliary and remedial services (Supplementary Instruction, English as a Second Language and Compensatory Education Services) provided to students
enrolled in nonpublic schools, also review
the guidance issued by the Office of Nonpublic School Services. The guidance document may be found at:
Guidelines for Auxiliary Services and Remedial Services (Chapters 192 and 193 for Nonpublic School Students ) .
Review additional guidance and information in the document “Clinic and Agency Requirement.”
1. Independent Child Study Team (CST) Evaluation in accordance with N.J.A.C. 6A:14-2.5.
An independent child study team (CST) evaluation
may be requested by a parent after the school district or
charter school has
conducted an initial
or
reevaluation. It is considered a second opinion conducted by certified professionals that are not employed by the school district or charter school. The
evaluations
include
a
psychological
evaluation,
a
learning
evaluation
and/or
social
history evaluation.
A
clinic/agency
may
provide
one,
two
or
all
three
types
of evaluation (psychological, learning, or social history).
a.
Location
of
Service
(select
all
that
apply):
Onsite at a clinic location approved by the NJ
DOE.
Offsite at Public Schools, Charter Schools, Approved Private Schools for Students with Disabilities (APSSDs), Nonpublic Schools.
Offsite at the student’s location.
Required Credentials of Service Providers
Relevant Regulations/Guidance
Standard NJ certification
for
the
foll
owing:
•
•
•
N.J.A.C.
6A:14-2.5(c)
•
•
•
Learn
ing
Disabilities
Teacher– Consultant
(L
DT-C)
N.J.A.C.6A:14-3.4
School
Psychologist
N.J.A.C.6A:14-5.1
and
N.J.A.C.6A:14-5.2
(Subchapter
5)
School
Social
Worker
2. CST Services to supplement existing local district services.
a. Location of Service (select all that apply):
Onsite at a clinic location approved by the NJDOE.
Offsite at Public Schools, Charter Schools, and APSSDs.
Required Credentials of Service Providers
Standard NJ certification for
• Learning Disabilities Teacher–Consultant (LDT-C)
• School Psychologist
• School Social Worker
Relevant Regulations/Guidance
• N.J.A.C.6A:14-2.5(a) an
d (
b
)
• N.J.A.C.6A:14-3.4
•
N.J.A.C.6A:14-5.1 and N.J.A.C.6A:14-5.2 (Subchapter 5)
3. Speech-Language Services (SLS).
Provided by a speech-language specialist when a district or approved private school is unable to hire sufficient staff to provide the service. May include
evaluation/reevaluation, IEP development, and direct therapy.
a. Location of Service (select all that apply):
Onsite at a clinic location approved by the NJDOE.
Offsite at Public Schools, Charter Schools, APSSDs and Nonpublic Schools.
Offsite at the student’s location.
Required Credentials of Service Provide
rs
Relevant Regulations/Guidance
Standard NJ Speech-Language Specialist cer
tification.
•
N.J.A.C.6A:14-2.5
Please
note:
The
speech
correctionist
certificate
is
no
l
onger
valid.
•
N.J.A.C.6A:14-3.1
through
N.J.A.C.6A:14-3.9
(Subchapter
3)
•
N.J.A.C.6A:14-5.1
and
N.J.A.C.6A:14-5.2
(Subchapter
5)
If
providing
services
in
nonpublic
schools,
review:
N.J.A.C.6A:14-
6.1 and N.J.A.C.6A:14-6.2
Page 5 of 23
Revised August 2023
4. Occupational Therapy (OT) Services.
May include evaluation & reevaluation, IEP and/or Service Plan development, and direct therapy.
a. Location of Service (select all that apply):
Onsite
at
a
clinic
location
approved
by
the
NJDOE.
Offsite at Public Schools, Charter Schools, APSSDs and Nonpublic Schools.
Offsite at the student's location.
Required
Credentials
of
Service
Provid
ers
Relevant
Regulations/Guidance
•
Standard
NJ
School
Occupational
Therap
ist
certification;
and
• N
.J.A.C.6A:14-2.
5
•
NJ
Occup
ational
Therapist
license
issued
by
the
NJ
Division
o
f
Co
nsumer Affai
rs.
•
N.J.A.C.6A:14-3.1
through
N.J.A.C.6A:14-3.9
(Subchapter
3)
•
N.J.A.C.6A:14-5.1
and
N.J.A.C.6A:14-5.2
(Subchapter
5)
If
providing
services
in
nonpublic
schools,
review:
N.J.A.C.6A:14-
6.1 and N.J.A.C.6A:14-6.2
Page 6 of 23
Revised August
2023
5. Physical Therapy (PT) Services.
May include evaluation & reevaluation, IEP and/or Service Plan development, and direct therapy.
a. Location of Service (select all that apply):
Onsite
at
a
clinic
location
approved by
the
NJDOE.
Offsite
at
Public
Schools,
Charter
Schools,
APSSDs
and Nonpublic
Schools.
Offsite at the student’s location.
Releva
nt Regulations/Guidance
Required Credentials of Service Providers
• Stan
dard NJ School Physical Therap
ist
cert
ification;
and
•
•
•
N.J.A.C.6A:14-2.5
N.J.A.C.6A:14-3.1 through N.J.A.C.6A:14-3.9 (Subchapter 3)
N.J.A.C.6A:14-5.1 and N.J.A.C.6A:14-5.2 (Subchapter 5)
NJ Physical Therapist Licens
e
•
If p
roviding servi
ces in nonpublic schools, review: N.J.A.C.6A:14-6.1
and N.J.A.C.6A:14-6.2
6. Counseling.
May include assessment for, and development of, IEP or Service Plan goals and objectives, direct counseling services.
a. Location of Service (select all that apply):
Onsite at a clinic location approved by the NJDOE.
Offsite at P
ublic Sch
o
o
ls, C
h
arter Sch
o
o
ls, APPSDs and Nonpublic Schools.
Offsite at the student’s location.
Required
Credentials
of
Service
Providers
Rele
vant
Regulations/Guidance
Standard
NJ
certification:
• N
.J.A.C.6A:14-2.
5
•
•
•
•
Sch
ool Social Worker
School Psychologist, or,
NJ Social Work License
NJ Psychologist License
•
•
N.J.A.C.6A:14-3.1
through
N.J.A.C.6A:14-3.9
(Subchapter
3)
N
.J.A.C.6A:14-5.1
and
N.J.A.C.6A:14-5.2
(Subchapter
5)
If providing services in nonpublic schools, review:
N.J.A.C.6A:14-6.1
and
N.J.A.C.6A:14
-6.
Page 7 of 23
Revised August
2023
location.
7. Behavior Modification Services.
May include conducting a functional behavioral assessment (FBA), development of a behavioral intervention plan (BIP), and direct intervention with students.
a. Location of Service (select all that apply):
Onsite
at
a
clinic
location
approved by
the
NJDOE.
Offsite
at
Public Schools,
Charter
Schools,
APSSDs
and Nonpublic
Schools.
Offsite at the student’s location.
•
NJDOE School Certification.
•
N.J.A.C.6A:14-3.1 through N.J.A.C.6A:1
4-3.9
(Subchapter 3)
•
Board Certified Behavior Analyst (BCBA).
•
Board Certified Assistant Behavior Analyst (BCaBA).
•
N.J.A.C.6A:14-5.1
and
N.J.A.C.6A:14-5.
2
(Subchapter
5)
•
Board Certified Behavior Analyst-Doctoral (BCBA-D).
If providing services in nonpublic
schools, review: N.J.A.C.6A:14-6.1
and N.J.A.C.6A:14-6.2
•
If the provider does not have any of the above credentials, the service provider must
hold at a minimum, a bachelor’s degree in education, psychology, or a related field
such as Applied Behavioral Analysis, Behavioral Sciences, Child Development, Child
Psychology or Social Work; and/or from an accredited institute of higher education.
•
If the provider does not have a BCBA, BCaBA, BCBA-D or a NJDOE teacher certificate,
the agency will need to submit a copy of the provider’s official college transcript
when submitting provider credentials to the OSE.
Required
for
Provision
o
f
Service
Note: The New Jersey Department of Education, Office of Special Education (OSE) cannot approve providers without licensure, certification, or a
bachelor’s degree to provide any service through a clinic or agency. Registered behavioral technicians (RBTs) and/or paraprofessionals who do not have
meet the degree requirements do not meet the minimum standards for approval by the OSE. LEAs and nonpublic schools may not contract with
clinics/agencies for the services of RBTs and/or paraprofessionals who do not meet the degree requirements.
Clinic/Agency acknowledges
all
speciali
sts
in
behavior modification
shall
work
under
the
supervision
of
certified
district
board
of
education
personnel.
Page 8 of 23
Revised August 2023
Required Credentials of Service Providers
Relevant Regulations/Guidance
Certification Subject Area/Grade Level and Codes
and
8. Home Instruction to replace academic instruction at school, per N.J.A.C. 6A:14-4.8, Program criteria: home instruction.
A student with a disability shall have his or her IEP implemented through one-to-one instruction at home or in another appropriate setting.
Note: the location of service is offsite at the student's location.
Req
uired Credentials of Ser
vice Providers
Relevant Regulations/Guidance
Requires standard NJ teacher certification: Teacher of Students with Disabilities or
certification by subject and/or by grade.
For a list of certifications, go to NJDOE Certification and Induction:
Certification Subject Area/Grade Level and Codes
• N.J.A.C.6A:14-4.
8
• N.J.A.C.6A:14-5.1 N.J.A.C.6A:14-5.2 (Subchapter 5)
9. Home Instruction to replace academic instruction at school, per N.J.A.C. 6A:16-10.1.
H
ome or out-of-school instruction due to a temporary
or chronic health condition (includes both general education and special education students).
Note:
the
location
of
service
is
offsite
at
the
student's
location.
Req
uired
Credentials
of
Service
Providers
Relevant Regulations/Guidance
Requires standard NJ teacher certification: Teacher of Students with Disabilities or
certification by subject and/or by grade. For a list of certifications, go to NJDOE
Certification and Induction:
•
•
•
N.J.A.C.6A:16-10.1
N.J.A.C.6A:14-5.1 and N.J.A.C.6A:14-5.2 (Subchapter 5)
Guidelines f
or Auxiliary Services and Remedial Services
(Chapters 192 and 193 for Nonpublic School Students
Page 9 of 23
Revised August
2023
Certification Subject Area/Grade Level and Codes
and
10. Home Instruction to replace academic instruction at school, per N.J.A.C. 6A:16-10.2.
Home or out-of-school instruction for a general education student for reasons other than a temporary or chronic health condition
Note: the location of service is offsite at the student's l ocation.
Required Credentials of Service Providers
Relevant Regulations/Guidance
Requires standard NJ teacher certification: Teacher of Students with Disabilities or
certificatio
n by subject and/or by grade. For a list of certifications, go to NJDOE
•
N.J.A.C.6A:16-10.2
• N.J.A.C.6A:14-5.1
and
N.J.A.C.6A:14-5.2 (Subchapter 5)
Certification and Induction:
Certification Subject Area/Grade Level and Codes
•
Guidelines for Auxiliary Services and Remedial
Services (Chapters 192 and 193 for Nonpublic
School Students
11. Evaluation, determination of eligibility, classification, and the development of a service plan for nonpublic school students.
Please note: Approved clinics/agencies must employ a full child study team.
Note: the location of service is offsite at a nonpublic school.
Requ
ired Credentials of Service Providers
Relevant R
egulations/Guidance
Requires standard NJ certification for each discipline:
Learning Disabilities
Teacher
-
Consultant
(LDT-C),
Schoo
l
Psychologist
and
School Social Worker.
• N.J.A.C.6A:14-5.1
and
N.J.A.C.6A:14-5.2
(Subchapter
5)
•
N.J.A.C.6A:14-6.1
and
N.J.A
.C.6A:14-6.2.
12. Supplementary
Instruction.
Provided to nonpublic students eligible for special education as an addition to the primary instruction for the subject
being taught.
Note:
the
location
of
service is
offsite
at
a
nonpublic
school.
Required Credentials of Service Providers
Relevant Regulations/Guidance
Requires standard NJ general education teacher certification by subject and/or by
grade.
• N.J.A.C.6A:14-5.1 N.J.A.C.6A:14-5.2 (Subchapter 5)
• Guidelines for Auxiliary Services and Remedial Services
(Chapters 192 and 193 for Nonpublic
School Students
Page 10 of 23
Revised August 2023
N.J.A.C.6A:14-5.2
(Subchapter
5)
13. English as a Second Language provided to nonpublic students who are identified as English Language Learners.
Note: the location of service is offsite at a nonpublic school.
Relevant Regulations/Guidance
Required Credentials of Serv
ice Providers
Requires standard NJ English as a Seco
nd Language certification.
• N.J.A.C.6A:14-5.1 and N.J.A.C.6A:14-5.2 (Subchapter 5)
• Guidelines for Auxiliary S
ervices and Remedial Services
(Chap
ters 192 and 193 for Nonpublic School Students
14. Compensatory Education in English Language Arts and mathematics provided to eligible nonpublic school students in accordance with an individual
student improvement plan.
Note: the location of service is offsite at a nonpublic school.
Required Credentials of Service Providers
Relevant Regulations/Guidance
Standard or CEAS Certification for Teacher of Supplemental Instruction in
Reading and Mathematics, Grades K–8
Standard NJ Certification Teacher of
Students with Disabilities
Standard NJ Certification Teacher of English
Standard NJ Certification
Teacher of Mathematics
Standard NJ Certification Elementary School Teacher Grades K-6
Standard NJ Certification Middle School with Subject Matter Specialization:
Language Arts/Literacy Specialization
in Grades 5-8
Standard NJ Certification Middle School with Subject Matter Specialization:
Mathematics in Grades 5-8
•
N.J.A.C.6A:14-5
.1 and
•
Guidelines for
Auxiliary Services and Remedial
Services
(Chapters
192
and
193
for
Nonpublic
School
Students
Page 11 of 23
Revised August 2023
15. School Nurse for Nonpublic Schools.
An on-going position as a school nurse in a nonpublic school.
Note: the location of service is offsite at a nonpublic school.
Required Credentials of Service Providers
Relevant Regulations/Guidance
•
An active license issued by the NJ Division of Consumer Affairs as a Registered
Professional Nurse (RN). In accordance with N.J.A.C. 6A:16-2.5.
•
A
School
Nurse
Certificate
issued
by
the
NJ
Department
of
Education
is not
required.
• N.J.A.C.6A:16-2.5
• N.J.A.C.6A:14-3.1 through Subchapter 3.9;
• N.J.A.C.6A:9: Professional Standards;
• N.J.A.C. Title 13 Department of Law and Public Safety,
Division of Consumer Affairs (for occupational licenses);
• N.J.S.A.18A:46A-1 et seq, Auxiliary Services (Nonpublic
Services (Nonpublic Schools); and,
• Section 504 of the Rehabilitation Act of 1973.
Page 12 of 23
Revised August 2023
16. Substitute Public School Nurse.
A temporary assignment when the NJ certified school nurse employed by a public school district (LEA) or approved private school for students with disabilities
is absent.
Note: the location of service is offsite at a public school.
Required Credentials of Service Providers
Relevant Regulations/Guidance
An active license issued by the NJ Division of Consumer Affairs as Registered
Professional Nurse (RN) and one of the following certifications issued by the NJ
Department of Education:
• For a non-instructional substitute: A Non-Instructional Substitute Schoo
l
Nurse Certificate or a Non-Instructional Standard School Nurse Certificate.
•
For an instructional substitute - school nurse teaching health related classes:
An Instructional Substitute School Nurse Certificate or a Standard
Instructional School Nurse Certificate.
• N.J.A.C.6A:16-2.5
• N.J.A.C.6A:9, Professional Standards
• N.J.A.C.6A:14-3.1 through Subchapter 3.9;
• N.J.A.C. Title 13 Department of Law and Public Safety,
Division of Consumer Affairs (for occupational licenses);
Please note: Time limitations on the number of days a substitute
may serve in the same position is dependent upon the required
credentials noted above. For more information, contact the
County Office of Education in the county where the school or
school district is located or visit the NJDOE website at:
Certification and Induction: Substitute Credentials.
Page 13 of 23
Revised August 2023
NJ EdCert
Part 3: Service Providers and Credentials
Instructions:
1. Clinics/Agencies are required to have a Minimum of three (3) professional direct service providers and/or at least one direct service provider per service. If
amending
an already approved agency, your agency will only need one provider unless the service requires more than one
provider.
2. Complete the
credential information for each service provider. Attach additional sheets as
necessary.
3. Submit
copies of provider licenses or
certificates.
Clinic/Agency Name:
Name of Individual Service
Provider
Please attach copies of
provider’s . If no
certificate or license (for
Behavior Modification
Services)-attach official
college transcript.
NJ Division of Consumer
Affairs License Number (if a
license is required)
NJ Division of Consumer
Affairs License Expiration
Date
Direct Service(s) to be
provided. Select the service as
indicated on the application.
Amendment applicants: please attach the provider's criminal history review approval under your agency's vendor code.
Page 14 of 23
Revised August
2023
Page 15 of 23
Revised August 2023
Part 4: Service Providers and Credentials for School Nursing Services
Instructions:
1. List the name of each nurse and complete the information in the relevant columns. All nurses are required to have a current license issued by the NJ Division
of Consumer Affairs.
2. Within the “Services to Be “Provided” place a (X) in appropriate columns.
3. For clinic/agency approval, a minimum of three (3) or more nurses must be listed. Make additional copies of this form as needed.
4. Submit copy of NJ EdCert certificate or substitute certificate issued by the County Office.
Clinic/Agency Name:
Name of Service Provider
Service: Nonpublic
School Nurse
(active RN License)
Service: Substitute
School Nurse (Active
RN License) NJDOE
Standard Certificate
NJ Division of Consumer Affairs
License Number and expiration
Date
For Substitute School
Nursing
services,
please attach
copy of NJ EdCert
or
Substitute Certificate issued by the
County
Office
or
school
district
is
located.
Please visit the NJDOE website at:
Certification
and
Induction:
Substitute
Credentials.
Amendment applicants: please attach the provider's criminal history review approval under your agency's vendor code.
Part 5: Delivery of Services and Operating Procedures
• New clinic/agency applicants are required to answer questions numbers 1 through 4. If an approved agency is seeking to
change location of services, please answer number 1.
• Initial and amendment applicants, if applying for Physical Therapy Assistant and/or Occupational Therapy
Assistant must check off all applicable acknowledgement statements.
1. The new clinic/agency applicant will be providing services as (select all that apply):
a. A clinic providing services onsite from the location of the business.
b. An agency sending qualified providers offsite to the public school, charter school, Approved Private School for
Students with Disabilities, and/or nonpublic school.
c. An approved clinic agency seeks to amend their delivery of services to either the following (select one):
i. Onsite from the location of the business
ii. Offsite to the public school, charter school, Approved Private School for Students with Disabilities, and/or
nonpublic school.
2. Identify the staff member(s) responsible for ensuring the validity of staff licenses, criminal history approvals, and other
credentials:
3. State the days and hours of clinic/agency operation:
4. Describe how the clinic/agency will maintain coordination and communication with the school districts or schools:
Please check the following statements to acknowledge compliance:
If hiring non-certified providers, such as certified occupational therapy assistants (COTAs), Physical Therapy
Assistants (PTAs), clinic/agency acknowledges COTAs and PTAs, shall work under the supervision of an
appropriately licensed and, where applicable, certified provider and in the presence and under the supervision of
a certified occupational therapist and certified physical therapist.
The Clinic/Agency will maintain clinic/agency procedures for ensuring the validity of staff licenses, criminal
history approvals, and other credentials through the NJDOE Office of Credentials and Licensing and/or the
Behavior Analyst Certification Board and/or the NJ Division of Consumer Affairs and the NJDOE Office of
Student Protection.
Clinic/agency acknowledges to maintain policies and procedures for collecting, maintaining, and verifying the monthly
service logs.
Clinic/Agency acknowledges assurance of the maintenance of a log, which includes the following: a list of
services provided, date, time, and location of the services provided; and the names of the professional staff
providing each service.
Page 16 of 23
Revised February 2023
Part 6: Required Business Documents
If application is an initial application or if amending an existing clinic/agency of either of the following: Onsite Location,
Ownership and/or adding an additional Onsite location.
Submit the following required documents with your application and check each item that is attached
A valid and current copy of a NJ Business Registration Certificate. Where appropriate, any licenses or permits
required by ordinances in effect within where the state, county, or municipality where the clinic or agency
provides its services shall be provided, as per N.J.A.C. 6A:14-5.2(a) 1
If providing services on-site at the clinic location, as per N.J.A.C. 6A:14-5.2 (c) 2, you must attach the following:
Certificate of Occupancy (CO).
Valid fire, safety, and health inspection certificates.
A description of the building, offices and grounds that demonstrates compliance with ADA regulations;
and
If providing services in a trailer or mobile unit placed on nonpublic school property, attach the approval
from the County Office of Education.
Page 17 of 23
Revised August 2023
New Jersey Department of Education
Office of Special Education
Clinic/Agency Required Policies Under IDEA Part B
Name of Clinic/Agency _________________________________
Part 7: Assurance Statement
1. In accordance with N.J.A.C. 6A:14-5.2(a)4, all clinic/agency service providers shall have a valid
Criminal History Review (CHR) approval issued by the NJDOE, Office of Student Protection for
each professional employed prior to providing services to students.
2. Providers may work for multiple clinics/agencies. Providers employed by more than one
clinic/agency must appear on the staff list for clinic/agency, must have licensure/certification to
provide the service, and have a valid CHR obtained from each clinic/agency on file.
a. Clinics/agencies may not subcontract with other providers.
b. Within seven (7) days of hire, the clinic/agency will forward a completed Staff Change
Request Form to OSE for each staff member providing direct services. A valid CHR
approval issued by the NJDOE, Office of Student Protection for each new service
provider listed shall be attached.
c. Whenever a clinic/agency changes through either merger, change in ownership, or the
location of its administrative offices, the clinic/agency shall notify the OSE in writing of
the change within seven (7) days. The clinic/agency shall submit required
documentation of the change as requested by OSE.
3. The clinic/agency shall submit an amendment to OSE when the clinic/agency changes the
location of onsite services or adds a location to provide onsite services. 5. In accordance with
N.J.A.C. 6A:14-5.1(d), approved clinic/agency services will not be initiated prior to the county
office of education being notified of the district’s purchase of services, with the exception of
Independent Child Study Team evaluation and medical services.
4. The clinic/agency will comply with the applicable regulations for implementing N.J.A.C. 6A:32-
7.3, et seq.,
student records. Specifically,
a. student records generated by a service provider at the responsible public school district
will be stored, maintained, and accessed at the public school in accordance with N.J.A.C.
6A:32-7.5(e)5.
b. when the services are provided onsite at the clinic or agency, at the nonpublic school, at
the approved private school, or at the student's home, the clinic/agency will assure that
the student records will be stored, maintained, and accessed by clinic or agency
personnel in a manner consistent with student records code in accordance with N.J.A.C.
6A:32-7.4 and N.J.A.C.6A:32-7.5.
c. additionally, the clinic/agency will forward applicable student records to the responsible
school district at least one time per year and/or upon completion of the service(s) to the
Revised August 2023
Page 18 of 23
New Jersey Department of Education
Office of Special Education
Clinic/Agency Required Policies Under IDEA Part B
Name of Clinic/Agency
_________________________________
stud
ent to enable the school district to fulfill its responsibilities under N.J.A.C. 6A:32-7,
et seq.
d. When a parent or other authorized agency or organization as per N.J.A.C. 6A:32- 7.5(a)
requests access to student records that were generated by clinic or agency service
providers, access will be requested of the school district and provided by the school
district in accordance with N.J.A.C. 6A:32-7.6.
e. When a request for records by a parent or other third party is presented to the
clinic/agency, the clinic/agency will forward the request to the school district and will
provide the school district with the requested student record(s).
5. Clinic/agency providers who are also employees of a district board of education, approved
private school, or nonpublic school shall not provide services to students who are the
responsibility of his/her employing district, approved private school, or nonpublic school.
Clinic/agency services shall not occur during the hours of the provider’s public school
employment, approved private school employment, or nonpublic school employment.
6. Professionals conducting evaluations in accordance with N.J.A.C. 6A:14-2.5 and 6A:14- 3.4, shall
be available during the school day to complete classroom observations.
7. A monthly service log shall be maintained for each student documenting the provision of
services. Please note this does not apply to clinic/agencies providing School Nurse Services.
8. The clinic/agency agrees to retain a certified accounting agency or maintains an accounting
system that complies with Generally Accepted Accounting Principles (GAAP).
9. The clinic/agency agrees to comply with all applicable requirements promulgated by the
Commissioner of Education and the State Board of Education regarding the Special Education
Medicaid Initiative (SEMI).
10. The clinic/agency administration and staff will maintain current knowledge of, and provide
services in compliance with:
a. New Jersey Administrative Code (N.J.A.C.) 6A:14 (Special Education); Individuals with
Disabilities Education Improvement Act 2004 (IDEA);
b. N.J.A.C. 6A:32-7.3 et seq. (Student Records);
c. Section 504 of the Rehabilitation Act of 1973;
d. New Jersey Statutes Annotated (N.J.S.A.) 18A:46A-1 et seq. (Chapter 192, Laws of 1977);
e. N.J.S.A. 18A:46-19.1 et seq. (Chapter 193, Laws of 1977);
Revised August 2023
Page 19 of 23
Director of Approved Clinic/Agency
New Jersey Department of Education
Office of Special Education
Clinic/Agency Required Policies Under IDEA Part B
Name of Clinic/Agency
_________________________________
f. N.J.A.C. 6A:
9 (Professional Licensure and Standards);
g. N.J. Department of Law and Public Safety statutes, and
h. Regulations governing licensed occupations; and other relevant state and federal laws,
including but not limited to, regulations prohibiting the exclusion of any persons due to
race, color, sex, creed, national origin or handicapping condition.
11. The clinic/agency will maintain its facilities/buildings/offices in compliance with the Americans
with Disabilities Act, (ADA) P.L. 101-336; and current municipal and/or county fire, safety, and
health standards.
ASSURANCE STATEMENT
Name of Clinic/Agency: _________________________________________________________
• To demonstrate compliance with Part B of the IDEA and N.J.A.C. 6A:14-1.1(b) and (c), the above-
named clinic/agency has read and understood the regulations applicable to the services selected on
this application and will adhere to applicable regulations and shall assure compliance with the above
stated policies.
• This assurance statement
supersedes any previous assurance statement signed on behalf of
the
clinic/agency
• The clinic/agency
shall maintain a copy
of the policies
for review upon request.
• The clinic/agency shall submit a copy of the policies and the signed assurance statement to the
NJDOE, Office of Special Education, via email to clinic@doe.nj.gov.
• The clinic/agenc
y shall submit a copy of the policies and the signed assurance statement to the
County Office
of Education.
The approved cli
nic/agency has read and understood the regulations applicable to the services
selected on this application and will adhere to the applicable regulations.
Signature
: ______________________________________________ Date: _____________________
Revised August 2023
Page 20 of 23
Page 21 of 23
RevisedAugust 2023
Acknowledgement of the Office of Special Education Clinic/Agency Procedures
I. After Approval:
A. Adding other services to your clinic/agency requires an Amendment Application that describes the
services,
includes
the
credentials
of
the
service
providers,
and
an
updated
Assurance
Statement.
Please
contact the
NJDOE
by
email at
to
request an
application.
B. The
clinic/agency
must
notify
the
NJDOE,
in
a
timely
manner,
of
changes
in
office
location,
contact
personnel
or
changes
in
the
organizational
structure
of
the
agency
(e.g.,
merger,
or
sale
of
the
clinic/agency
to
another
entity).
Please
contact
the
NJDOE
by
email
at
to
request
the appropriate
form.
II. Special Notice:
A. Clinics and agencies are not permitted to subcontract with other clinics or agencies to share service
providers. Please reference NJDOE Approved Clinic and Agency Subcontracting and Staff Sharing
Broadcast.
III. Continued Communication
:
A. The Office
of Special
Education
(OSE)
r
equir
es
use of email to facilitate
communication.
The OSE will
share pertinent information such as changes in clinic/agency procedures and updates in Department of
Education
requirements.
In addition,
approved
clinics and agencies
can utilize
email
communication
to
request
information
and to provide
information
regarding
staff changes
(hiring
and termination
of
service
providers)
as required by
regulation.
The
approved
clinic/agency
must establish an email
account for the clinic/agency. The email account should meet the standards outlined here:
B. The email address has the clinic/agency name as part of the address. For example:
C. If there needs to be one central email address per clinic/agency for communication that is accessible
to
the clinic/agency
director or coordinator
and have
the capability to accept large amounts of
information
(i.e., attachments) and to accept and reply to this office’s emails.
IV. Clinic/Agency
’
s designated Office of Special Education Email address:
V. Change Request Forms
A. A. To notify the NJDOE that a service provider has been hired, complete the top of chart on the Staff
Change Request Form Criminal History Review (CHR) Approval in accordance with N.J.A.C. 6A:14-5.2(a)4i.
(within seven (7) calendar days whenever a professional staff member (service provider) leaves the agency,
or a new service provider is hired. You may find the forms on the NJDOE Special Education Directories
webpage (towards the bottom of the page)
B. The form must be forwarded by email to clinicagency@doe.nj.gov. Please list the names of the service
providers in the subject line of the email.
VI. Maintenance of Approval:
A. After approval, a clinic or agency will be required to comply with the regulations set forth in the regulations
governing DOE-approved clinics/agencies as well as Office of Special Education procedures to maintain
their approval as outlined above.
Required: Please check off to acknowledge the to assure the procedures of the New Jersey Department of Education
have been read and understood and the forms and documentation will be submitted as required. The applicant is also
assuring they understand that if any administrator, supervisor, employee, or contractor provides erroneous or misleading
information, fails to provide required documentation, and/or acts in noncompliance with the DOE procedures or any state
and federal statutes and regulations, DOE approval will be revoked, and legal action may ensue.
Submission of Required Documents/Information
Required Document/Information
Yes/No
First page of application filled out and dated.
Checked off services to be provided
Part 3 and/or 4: Submitted credentials of three (3) individual providers
Part 3 and/or 4: Submitted a provider qualified per service requested
Part 5: Answered questions 1-4
Part 5: Checked off acknowledgements
Part 6: Submitted business formation paper and if out of state submitted NJ Business Registration
Certificate
Part 6: If providing services onsite, clinic/agency submitted all required building documents.
Part 6: Submitted description of building that demonstrates compliance with ADA regulations.
Authorized official signed the Assurance Statement
Clinic/Agency provided an email address for agency according OSE’s requirements and guidelines
Reviewed Office of Special Education Clinic/Agency procedures
Clinic/Agency checked off acknowledgement of the Office of Special Education Clinic/Agency
procedures
Page 22 of 23
Revised August 2023
For NJDOE Office of Special Education Internal Use Only
Name of Reviewer:
Date of Review (mm/dd/yy):
The applicant is approved for the following services (select all that apply):
Independent Child Study Team (CST) Evaluation
CST Services to supplement existing local district services
Speech Language Therapy Services
Occupational Therapy Services
Occupational Therapy Assistant Services
Physical Therapy Services
Physical Therapy Assistant Services
Counseling Services
Behavior Modification Services
Home Instruction- as per N.J.A.C. 6A:14-4.8
Home Instruction – as per N.J.A.C. 6A:16-10.2
Home Instruction-as per N.J.A.C. 6A:16-10.1
Substitute Public School Nurse
Nonpublic Services as the following (select all that apply):
Evaluation, determination of eligibility, classification, and the development of a service plan for nonpublic
school students.
Supplementary Instruction
English as a Second Language (ESL)
Compensatory Education Services
Nonpublic School Nurse
Page 23 of 23 Revised
August 2023
