Extended School Year (ESY) Eligibility Determination Form

Use it for IEP team meetings where the group must decide whether a student qualifies for Extended School Year services and, if so, what the service plan should include. It is designed for special education case managers, school psychologists, related service providers, and administrators who participate in the decision. Parent or guardian input can also be captured in the form. It works best when the team needs a clear record of both the eligibility rationale and the proposed services.

This template captures the submission purpose, consent acknowledgment, and whether the parent or guardian was notified, followed by student and IEP identifiers. It then records the eligibility decision, the basis for that decision, the data sources reviewed, and a short decision summary. The ESY service plan section captures dates, delivery model, setting, frequency, and notes. The final section records team members, parent input, and sign-off details so the record is complete.

ESY eligibility is typically reviewed during the IEP process for the applicable planning period, often before the end of the school year or when the team is reviewing summer services. This form is not meant for daily use; it is a decision record used when the team evaluates whether services are needed to support continued progress or prevent substantial regression. If your district has a different cadence, the form can be adjusted to match that timeline. The key is to document the decision at the point it is made.

The eligibility basis should reflect the actual data and team reasoning used to decide ESY, such as progress monitoring, regression and recoupment data, teacher observations, related service input, or other IEP-relevant evidence. Keep it specific to the student rather than using generic language. If the team considered multiple factors, summarize them in plain language and connect them to the decision. Avoid vague statements that do not show how the conclusion was reached.

It helps the team maintain a clear audit trail of the decision, the data reviewed, and the service plan that follows. The structure also supports good documentation practices by separating eligibility, service planning, and sign-off into distinct sections. Because it is a school form that may include student information, keep data minimization in mind and collect only what is needed for the ESY decision. If your district requires additional notices or procedural safeguards, those can be added as custom fields.

A common mistake is recording only the final yes/no decision without explaining the basis for it. Another is leaving the service plan too vague, such as listing ESY without dates, frequency, or delivery model. Teams also sometimes forget to capture parent input or the names of the participants who made the decision. This template is built to reduce those gaps by prompting the team to document each part of the process.

Yes. You can add district-specific eligibility criteria, state-required notices, or additional sign-off fields without changing the core structure. Many districts also customize the service plan section to match their scheduling, staffing, or transportation workflows. If your process requires a separate prior written notice or meeting minutes, this form can link to those records. Keep the core fields stable so the decision remains easy to review later.

Meeting notes and email can capture the conversation, but they often leave out key fields, make review harder, and create inconsistent records across students. A dedicated form gives the team a repeatable structure for the eligibility decision, service plan, and sign-off. That makes it easier to find the record later and easier to confirm that the same process was used for each student. It also reduces the chance that important details are buried in a long narrative.