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Run: Extended School Year (ESY) Eligibility Determination Form

An Extended School Year (ESY) Eligibility Determination Form for documenting the team’s decision, the basis for eligibility, and the proposed service plan fo...

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Submission Notice and Consent

Purpose of submission

Acknowledgment of records use and disclosure (required)

Yes No N/A

Parent/guardian notified of ESY review (required)

Student and IEP Identification

Student ID (required)

Use the district or student information system identifier; do not enter SSN.

Student name (required)

Current IEP date (required)

ESY review date (required)

Case manager (required)

Eligibility Determination

Is the student eligible for ESY services? (required)

Primary basis for the decision (required)

Data sources reviewed (required)

Decision summary (required)

Summarize the team's rationale, including any relevant regression/recoupment or skill maintenance data.

ESY Service Plan

Service start date (required)

Service end date (required)

Service delivery model (required)

Service setting (required)

Service frequency (required)

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 (required)

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 (required)

Submission date (required)

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Email (required)

Your name (optional)

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