ESY WORKSHEET FOR CONSIDERATION OF SERVICES
Instructions: Below are areas of possible discussion points. Attach supporting documentation for any areas checked (√).
R
egression and Recoupment
With an interruption in instruction, the student is likely to lose critical skills or fail to recover these skills within a
reasonable time.
There is a possibility of substantial regression of critical skills caused by an interruption in instruction.
N
ature and/or Severity of Disability
The student requires a consistent and highly-structured program due to the severity of the disability.
The student would be at educational and/or physical risk with an interruption in his/her programming. Please describe:
The student requires additional assistance with his/her behavior to maintain skills learned the past school year. Please
describe:
The student’s (mental, emotional, physical) health or the chronic nature of his/her disability requires additional assistance
to maintain skills. Please describe.
C
ritical Stages and Areas of Learning
A break in instruction might jeopardize the student’s emerging skills or compromise his/her progress in one or more skill
areas. Describe emerging skills below:
Progress in any of the critical life skills identified by the IEP is potentially jeopardized by an interruption in instruction.
The student’s vocational needs require additional support either not provided or typically found during the regular school
year. Please describe:
The student’s transitional needs require additional support not found in the regular school year. Please describe:
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1. Given the answers to questions in this checklist, should the student be considered for ESY services?
Yes No
2. What kinds of services are necessary to address the unique needs of this student?
3. What activities, outside of those provided in a regular school year, would help the student benefit from his/her educational
program?
4. When would be the best time for the student to participate in his/her needed services?
5. What is the desired outcome of ESY for this student?
6. Who will coordinate and monitor the provision of ESY services to the student in the event that they are offered?
7. Additional comments or concerns:
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