Services / ESY services entry
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Last Name
First Name
Meeting Date
1. Items for all students:
Teacher/provider name*
Teacher/provider name*
(The teacher name does
not
appear on the printed form, only the teacher code.)
If the teacher is not listed in the pop-up, try entering the name or teacher code
here:
You can also select by teacher
assignment.
School*
School*
If the school is not listed in the pop-up, try entering the school name or code
here:
Service*
Service*
Primary
Primary
Yes
No
Yes
No
Report to CASEMIS
Yes
No
Yes
No
Start date*
Start date*
End (evaluation) date
End (evaluation) date
Location type*
Location type*
Provider type*
Provider type*
Provider/responsible agency*
Provider/responsible agency*
(appears on the printed form)
NOTE: A provider type of "California Childrens Services 310" for a current service will cause the CCS box to be checked on the Educational Services form (5B).
Extended school year
Extended school year
Yes
No
Yes
No
2. For infant (age 0-2) services:
†
The following items are required for infant services. However, they can also be used for non-infant services as well. †In addition, they may be still be required for state submissions of educationally-related mental health services (ERMHS).
Provider type
Provider type
NOTE: A provider type of "California Childrens Services 310" for a current service will cause the CCS box to be checked on the Educational Services form (5B).
Frequency code
Frequency code
Duration, minutes per session
Duration, minutes per session
3. Other items:
Auxiliary service location
Auxiliary service location
Delivery model
Delivery model
Consult
Consult
Yes
No
Yes
No
LEA district
LEA district
Comments
Comments
Provider/responsible agency
Provider/responsible agency
4. For non-infant services:
5. For discontinued services:
The following items should be specified when the service has been discontinued:
Drop date
Drop reason
Drop reason
(primary service only)
Drop code or reason
Drop code or reason
(non-primary service only)
5. For discontinued services:
(for information only, no entry permitted here)
Drop date
Primary drop reason
-
Non-primary drop reason
-
*Required items