310 West Street, Elizabeth, IL 61028
Phone: (815) 599-1947 Fax: (815) 858-2195 Web Address: www.northwestcoop.com
Guidelines for Determining Extended School Year (ESY)
Student Name: ________________________________________ DOB: ________________ Grade:______
District/School: __________________________________________________________________________
IEP Meeting Date: ____________________________________
Instructions
If all answers are “No”, the student does not qualify for ESY services. If there are any “Yes” answers, the IEP
team should seriously consider ESY services. Note: A “Yes” answer by itself, does NOT mean a child is in need of
ESY services, simply that services should be considered.
I. Service(s) being considered (check all that apply):
*Related Services must be educationally relevant.




Instructional-LEA
Speech-Language
Occupational Therapy
Physical Therapy




Itinerant Hearing
Itinerant Vision
Other_____________________
Other ____________________
II. Questions to Address:
Area
Goal Areas of Concern
Questions
Will acquisition or maintenance of the skill significantly enhance the student’s ability
to function independently?
Goal Areas of Concern
Does the lack of this skill represent a barrier to continuous progress or selfsufficiency?
Goal Areas of Concern
Is the student at a critical stage of development where the “window of opportunity”
will be lost if ESY Services is not provided?
Regression
Is there documented information that would lead the team to believe that there will be
regression of skill? If yes, attach documentation.
Regression
If regression has not occurred in the past, does the team believe that a serious potential
for regression exists?
Regression
Is the student’s need so great that he/she cannot suffer even a modest amount of
regression and recoupment that would otherwise be acceptable?
Rare and Unusual
Is continuous or year around treatment an integral part of the methodology deemed
appropriate for this student?
Rare and Unusual
Are there other unusual circumstances that are a factor in considering the need for
ESY services?
If there are “yes” answers, please provide explanations in an attachment or on the back of this form.
Yes
No
Meeting the special needs of all students in Northwest Illinois
_____________________________________________________________________________________________________________________________
Serving Dakota, East Dubuque, Galena, Lena-Winslow, Orangeville, Pearl City, River Ridge, Scales Mound, Stockton, Warren, Freeport and West Carroll
SECTION 1-RATIONALE: Based upon a thorough review of the student’s IEP, what is the IEP team’s rationale and documentation for
recommending an ESY program to meet FAPE (including consideration of Specialized Transportation) requirements for this student?
SECTION 2-IEP INFORMATION: Attach ESY goal(s).
SECTION 3-TYPE OF SERVICES TO BE PROVIDED DURING ESY:
Instructional Services
Provider Name_____________________________________________________________________
ESY Dates: __________________________________ #Min/Session: ______ Total Sessions: ______
Related Services
Direct
Consult
Related Service
Location
Amount/Frequency
of Services
ESY Dates
Provider
(District or NWSE)
Outside Agency
Services:_________________________________________________________________________________________________
Begin:___________________ End: ________________________ # Min/Session: _________ Total Sessions: _________
PARENTS WILL BE NOTIFIED OF THE EXACT TIMES, DATES AND LOCATION WHERE SERVICES WILL BE SCHEDULED.
02.28.2011