Extended School Year (ESY) Eligibility Worksheet (p. 2) |
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Student Name |
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Date of Birth |
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IEP Date |
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1. |
The student demonstrates a pattern of past regression in skills as evidenced by breaks of more than four weeks. |
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Comments (describe the degree, minimal or serious, of actual or likely regression following a school break) |
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Comentarios (describir el grado mínimo o grave, de la regresión real o probable después de un de receso escolar) |
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3. |
Describe the student's rate of learning (as compared with the student's ability to recoup after a break). |
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Describir ritmo de aprendizaje (en comparación con la capacidad del estudiante para recuperar después de un receso) del estudiante. |
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4. |
Does the IEP team feel the student's disability will continue indefinitely or for a prolonged period of time? |
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Comments (describe the degree, minimal or serious, of actual or likely regression following a school break). |
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Comentarios (describir el grado mínimo o grave, de la regresón real o probable después de un de receso escolar) |
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Describe the degree, nature and severity of the student's disability |
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Describir el grado, la naturaleza y la severidad de la discapacidad del estudiante |
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5. |
Does the IEP team feel it will be impossible or unlikely the student will attain self-sufficiency and independence expected in view of the student's disability following a break? |
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Comments (describe the degree, minimal or serious, of actual or likely regression following a school break). |
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Comentarios (describir el grado mínimo o grave, de la regresíon real o probable después de un de receso escolar) |
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6. |
Is the student at a critical point of skill acquisition or readiness where their ability to acquire the skills will be lost or greatly reduced as a result of an interruption of services? |
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If yes, describe: |
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En caso afirmativo, describa: |
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7. |
Are there any other issues concerning the student's physical, medical condition, emotional, social, behavioral, mental health, academic and/or vocational issues, and his/her ability to be with typically developing peers that may be adversely impacted if the student does not receive ESY services? |
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If yes, describe: |
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En caso afirmativo, describa: |
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