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]