Extended School Year (ESY) Eligibility Worksheet (p. 2)
Page help

 
 
 
  Student Name     Date of Birth   IEP Date
 

 
1. The student demonstrates a pattern of past regression in skills as evidenced by breaks of more than four weeks.  
 
   
  Comments (describe the degree, minimal or serious, of actual or likely regression following a school break)  
 
 
 
 Espaņol  (...)
 
 
 
2. What is the estimated amount of time it takes or it may take the student to regain the prior level of knowledge skills, benefits or functioning following a school break?  
 
    Other:    
  Comments  
 
 
 
 Espaņol  (...)  (...)
 
 
 
3. Describe the student's rate of learning (as compared with the student's ability to recoup after a break).  
 
 
 
 
 Espaņol  (...)
 
 
 
4. Does the IEP team feel the student's disability will continue indefinitely or for a prolonged period of time?  
 
   
 
  Comments (describe the degree, minimal or serious, of actual or likely regression following a school break).  
 
 
 
 Espaņol  (...)
 
 
 
  Describe the degree, nature and severity of the student's disability  
 
 
 
 Espaņol  (...)
 
 
 
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?  
 
   
 
  Comments (describe the degree, minimal or serious, of actual or likely regression following a school break).  
 
 
 
 Espaņol  (...)
 
 
 
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?  
 
   
  If yes, describe:  
 
 
 
 Espaņol  (...)
 
 
 
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?  
 
   
  If yes, describe:  
 
 
 
 Espaņol  (...)