FORM 33 EXTENDED SCHOOL YEAR (ESY) ELIGIBILITY WORKSHEET

 

The ESY worksheet was formally adopted by the Forms Committee in February, 2013 as an optional form in order to assist IEP Teams when making Extended School Year (ESY) determinations. The worksheet is to describe and properly document the recoupment and regression that determines the need for ESY.

 

Definitions: Explains exactly what ESY is and how/why it is determined to be needed by the student. This section also provides the definition for Rate of Recoupment and Regression and Recoupment in order for the IEP to completely discuss the needs of the student.

 

Question Section:  Each of the questions 1 through 5 must be discussed and determined to be Yes” or No for each item.

 

Question 1: The IEP Team must determine if the student is unable to regain skills in the same manner and timeline as their general education peers.  If the student is not able to regain skills in such a manner the IEP Team must identify the area(s) in which the student is does not make progress in a manner similar to his/her peers.

 

Question 2: This question documents the loss of skills a student exhibits during short breaks throughout the school year which may determine the need for ESY services. If a student shows a loss of skills during s short break the IEP Team must identify the area(s) which is affected.

 

Question 3: This question identifies essential skills or crucial areas of improvement a student is achieving that would otherwise be lost should the student have a lengthy break of service. The IEP Team is to identify the skills or areas that would be adversely affected should the student have a significant break in service.

 

Question 4: This questions summarizes the above information indicating the loss of skills that would occur without ESY

services.

 

Question 5: This questions documents the relationship between the student’s disabling condition and the need for

ESY services.

 

 

Should any of the 5 Questions receive a Yes answer, Page 2 of the Worksheet must be completed.

 

Page 2 of the ESY Worksheet describes in more detail the need for services. The IEP committee is responsible for ensuring that a student receives a free appropriate public education (FAPE), and must determine the special education and related services necessary to meet the student's unique needs. This section provides this justification.

 

Failing to master IEP goals does not automatically make a student eligible for ESY services

 

 

 

[Excerpted from the State SELPA IEP Manual, July, 2013]