Request for Enhanced Rate for Special Care

E-167a

10-21

Reason for Request: this benefit is available for a child with disabilities or continual behavioral problem who has a need for specialized support services. It is available for a child who has a temporary or permanent disability and requires special care services by their caretaker. The rate is $7.25/hour regardless of age or environment. Regional child care provider enrollment staff approval is required.

Parent Name:	Case No.
EES Worker:	Date of Request

TO BE COMPLETED BY EES CASEWORKER:

I. Identification:

Name of Child:	DOB:
Child’s KsCares ID #:	SSN:
Child’s Address (include town):
Telephone Number:

Parent/Caretaker/Guardian Information (if different from above):

Name:

Address (Include town):

Telephone Number (if different from above):

TO BE COMPLETED BY PARENT:

II. a. Describe Reasons for Child’s Need, including behavior issues, if applicable:

(Attach required documentation from skilled professional .)

b. Is the condition:

ongoing?

short term?

occasional?

If the condition is temporary, date it is expected to end:

Please explain:

c. Has the child been expelled or removed from care situations at the request of the provider due to behaviors?

Yes:	No:	If yes, please explain:


Is the behavior linked to a medical condition?
Yes:	No:	If yes, please explain:

TO BE COMPLETED BY PARENT:

III. Child Care Provider Information:

Name:

Address (Include town):

Telephone:

TO BE COMPLETED BY SKILLED PROFESSIONAL:

IV. Signature & Title of Authorized Skilled Professional Identifying need:

Name (Print Name):	Title:
Signature:

(Agency Use Only)

Signature of EES Program Administrator or Designee:

Name:

Phone:

Date:

For use by Child Care Provider Enrollment Staff Only:
Enhanced Rate:	Denied:	Approved:

Comments:
Provider Enrollment Signature:		Approval Date:

Distribution: EES file, Regional Child Care Enrollment file

Instructions for Enhanced Rate for Special Care:

Completion of form ES-1627a is to be initiated by the EES caseworker at the request of the parent.

The family must be eligible for the child care subsidy. The family should request the enhanced rate for special care from the EES worker for a specific child care provider. A parent may request the enhanced care rate for services from any enrolled DCF provider.

The child must have ONE or MORE of the following conditions:

Developmental age lower than chronological age and requires assistance via special supervision
Movement impairment: Requires special assistance or unable to move
Sensory impairment: Requires special environment modifications or assistance
Hygiene, toileting and feeding: Requires assistance or special equipment unusual to the child’s age
Emotional impairment including challenging behavior: Requires special equipment or assistance/special supervision
A chronic medical condition requiring close supervision, monitoring and/or administration of medications

The parent provides ONE or MORE of the following as documentation of need:

IFSP/IEP indicating the need for special assistance or supervision
Observations/written documentation from a skilled* professional familiar with the child’s needs and abilities indicating need for special assistance or supervision

*A skilled professional would be a professional such as a physician, psychologist, special education teacher, public health nurse, social worker, etc.

The parent provides a signed statement from the child care provider:

* Indicating what exceptional services will be provided. For example: one-on-one supervision, respiratory management, hygiene requirements unusual for the age of the child.

* The provider should also provide documentation of any current special training acquired or needed to care for the child.

* Documentation of training or a plan to acquire training must be included.* The provider must be enrolled or in the process of becoming enrolled in the DCF child care subsidy program.