Extended School Year Worksheet Template - South Bend Community School Corporation

ADVERTISEMENT
South Bend Community School Corporation
Special Education Department
 
Extended School Year Worksheet
IEP Date:____________________
Student Name: __________________________ SBCSC ID#: ______________ STN#: _____________________
1. Critical Skill(s) Considerations:
a. What is the student's age? ____________
b. Regression of critical skills: Define critical skills that have regressed:________________________
______________________________________________________________________________
Data showing regression of these skills (be specific): ____________________________________
______________________________________________________________________________
Documentation showing regression must be included/attached:
IEP Progression of Goals/Progress Report
Behavior Checklists
Parent Report
Documented Observations by Staff
Test/Assessments
Other
Related Service Information
Data Sheets
How long did it take to recoup lost skills? ______________________________________________
Has the IEP been revised to address the regression? _____ Describe: ______________________
______________________________________________________________________________
c. Critical Skill required in variety of environments:
Describe environments in which critical skills will be necessary for the student: ________________
______________________________________________________________________________
d. Assistance Required:
Does the student require the assistance of another person to perform the skill? ________________
Describe:_______________________________________________________________________
Major Questions:
Describe the critical stage and why a window of opportunity would be lost: ___________________
______________________________________________________________________________
Describe how the ability of the student to function will be significantly impaired by the loss of skills:
______________________________________________________________________________
If there is no significant regression, describe the need for a more restrictive environment if ESY
services are not given: ____________________________________________________________
______________________________________________________________________________
2. Special or Unusual Circumstances:
Considerations/Questions:
Describe any unusual circumstances that are possible factors necessitating the provision of ESY
services: ______________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Case Conference Committee Recommendation:
Yes
No
ESY Service(s) is/are required to provide this student with a free appropriate public
education.
8/4/10
South Bend Community School Corporation
Special Education Department
 
Extended School Year Worksheet
IEP Date:____________________
Student Name: __________________________ SBCSC ID#: ______________ STN#: _____________________
1. Critical Skill(s) Considerations:
a. What is the student's age? ____________
b. Regression of critical skills: Define critical skills that have regressed:________________________
______________________________________________________________________________
Data showing regression of these skills (be specific): ____________________________________
______________________________________________________________________________
Documentation showing regression must be included/attached:
IEP Progression of Goals/Progress Report
Behavior Checklists
Parent Report
Documented Observations by Staff
Test/Assessments
Other
Related Service Information
Data Sheets
How long did it take to recoup lost skills? ______________________________________________
Has the IEP been revised to address the regression? _____ Describe: ______________________
______________________________________________________________________________
c. Critical Skill required in variety of environments:
Describe environments in which critical skills will be necessary for the student: ________________
______________________________________________________________________________
d. Assistance Required:
Does the student require the assistance of another person to perform the skill? ________________
Describe:_______________________________________________________________________
Major Questions:
Describe the critical stage and why a window of opportunity would be lost: ___________________
______________________________________________________________________________
Describe how the ability of the student to function will be significantly impaired by the loss of skills:
______________________________________________________________________________
If there is no significant regression, describe the need for a more restrictive environment if ESY
services are not given: ____________________________________________________________
______________________________________________________________________________
2. Special or Unusual Circumstances:
Considerations/Questions:
Describe any unusual circumstances that are possible factors necessitating the provision of ESY
services: ______________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Case Conference Committee Recommendation:
Yes
No
ESY Service(s) is/are required to provide this student with a free appropriate public
education.
8/4/10

Download Extended School Year Worksheet Template - South Bend Community School Corporation

329 times
Rate
4.6(4.6 / 5) 20 votes
ADVERTISEMENT