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Extended School Year Services (ESY) - The Special Education Team

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Donetta - page 3<br />

7/1999<br />

Revised 8/2004<br />

Page ____ of ____<br />

EXTENDED SCHOOL YEAR FOR ____________________ (I-15)<br />

_____________________ SCHOOL DISTRICT<br />

Does the child require extended school year (<strong>ESY</strong>) services to receive a free and appropriate<br />

public education (FAPE)?<br />

� Yes � No<br />

If no, explain reasons rejected:<br />

If yes, identify which annual goals, including benchmarks or short term objectives, will be<br />

addressed during <strong>ESY</strong>:<br />

Goal: To develop meaningful communication skills.<br />

Objective: To increase the level of communication skills using an augmentative<br />

communication device.<br />

Specify all needed services:<br />

I. <strong>Special</strong> <strong>Education</strong><br />

Communication skills using an augmentative<br />

communication device.<br />

II. Related services<br />

III. Supplementary aids and services - aids, services, and<br />

other supports provided to or on behalf of the student in<br />

regular education or other educational settings<br />

Activity packets to promote use of augmentative<br />

communication device<br />

IV. Program modifications or supports for school personnel<br />

that will be provided<br />

Instruction to parents in regard to use of augmentative<br />

communication device and activity packets<br />

Frequency/<br />

Amount<br />

3 hours per<br />

week<br />

3 hours per<br />

week<br />

Provided<br />

weekly<br />

1 hour<br />

Location<br />

<strong>Special</strong> Ed<br />

Classroom<br />

Home &<br />

community<br />

settings<br />

Home<br />

Home<br />

Duration<br />

(beginning and<br />

ending dates)<br />

June 11–<br />

August 15<br />

June 11 -<br />

August 15<br />

Week of June 2<br />

CESA #9: 1999 Determining <strong>ESY</strong> <strong>Services</strong>, Revised 2004 34

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