Education Data Advisory Committee Approval Stamp

School Health Services Program FY 2021-22 Reimbursement Spending Report to CDE

Form Login Account:
New Users / Returning Users CLICK HERE to setup or return to your account for this form. Creating an account enables you to return to this form and your submitted results. An account will also enable you to partially complete this form and return later to finish the form. The account you establish is only for this form. Enter numbers only in fields requesting a number, do not type words. Use tab key or mouse to move to next box. Select the categories where your district spent funds, this will populate the forms with the items you need to answer. If no funds were spent on a category, do not select it. No need to enter zeros.

Administrative Expenditure Report

In the section below, please provide total expenditure amounts for the categories present. If no funds were spent in an admin category, enter "0" for that line item. For expenditure amounts outlined below, please provide a brief description of what is included in the total amount for that line item.
As a reminder, it is recommended that total admin costs not exceed 20% of total expenditures for a program. This is exempt for new districts participating in the School Health Services program. For questions or concerns, please contact Omar Estrada (
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Total Administrative Expenditures:

Health Services Expenditure Report

Select the Health Service categories where your district spent funds for FY 2021-22. Your selection will help to populate only the questions that you need to answer. If you need further assistance, please contact Omar Estrada
Select "NA/No reimbursement dollars were spent" if your district did not spend reimbursement dollars to provide health services. Selecting this option will not allow you to submit your report with other health service categories selected.
Select the Health Service Category(s) in which your district/BOCES spent money: *


Nursing Category Expenditures * 🛈
Total Nursing Expenditure 🛈

Mental Health

Mental Health Category Expenditures * 🛈
Total Mental Health Expenditure 🛈

Student Health

Student Health Category Expenditures * 🛈
Total Student Health Expenditure 🛈

Special Service Providers

Special Service Providers Category Expenditures * 🛈
Total Special Service Providers Expenditure 🛈

Outreach & Enrollment

Outreach & Enrollment Category Expenditures * 🛈
Total Outreach & Enrollment Expenditure 🛈


Transportation Category Expenditures * 🛈
Total Transportation Expenditure 🛈

Summary of Expenditures

Total Administrative Expenditures: 🛈
Total Health Service Expenditures: 🛈
Total Health Service FTE: 🛈
Total Funds Expenditure for FY 2021-22: 🛈

Annual Notification Acknowledgement & Intent to Continue Participation

1. Public agencies (e.g. public school districts) must provide written notification to parents prior to accessing a child's public benefits for the first time, and annually thereafter. Satisfying this requirement may vary by public agency. 

The full list of requirements for the annual notification to parents may be found on the U.S. Department of Education website. Please consult your district's legal team concerning questions related to the relevant regulations of the annual notice.
 * 🛈
2. Does your district intend to continue its participation in the School Health Services program for the next fiscal year (FY 2023-24)?

If the "NO" option is selected, the medicaid coordinator listed on this report will receive a follow-up for confirmation.
 * 🛈
EDAC Approval Stamp for 2019-20
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