Extended School Year (ESY) Eligibility Determination Form

Documents the team’s ESY eligibility decision and proposed service plan for a student with an IEP.

Submission Notice and Consent

• Purpose of submission
• Acknowledgment of records use and disclosure
• Parent/guardian notified of ESY review

Student and IEP Identification

• Student ID
  Use the district or student information system identifier; do not enter SSN.
• Student name
• Current IEP date
• ESY review date
• Case manager

Eligibility Determination

• Is the student eligible for ESY services?
• Primary basis for the decision
• Data sources reviewed
• Decision summary
  Summarize the team's rationale, including any relevant regression/recoupment or skill maintenance data.

ESY Service Plan

• Service start date
• Service end date
• Service delivery model
• Service setting
• Service frequency
  Example: 3 times per week, 30 minutes per session.
• Implementation notes
  Include staffing, transportation, accessibility, or scheduling notes needed to implement the plan.

Team Members and Sign-Off

• Team members present
  List names and roles of participants present for the ESY determination.
• Parent/guardian input summary
  Summarize any parent or guardian concerns, preferences, or questions relevant to ESY.
• Prepared by
• Submission date