LEE COUNTY SCHOOLS
Extended School Year (EYS) Services Determination
Documentation Form
Appendix B
Student Name: ________________________________________
Meeting Date: _________________
DOB: _______________
Grade: __________
School Year: ___________________
Teacher: ______________________________________________
School: ________________________
Eligibility is determined by the IEP team and based on (a) progress-monitoring and (b) predictive factor
data. Reference Extended School Year (ESY) Service Guidelines as needed.
1. Summarize Progress-Monitoring Data on current, annual IEP goal(s) and/or objective(s) with attention to
data points collected before and after extended breaks.
2. Analyze Progress-Monitoring Data to determine whether or not there was severe regression and
recoupment on current, annual IEP goal(s) and/or objective(s) during extended breaks.
NOTE: Severe Regression/Recoupment occurs when amount of time required to recoup or regain skill/level of
performance becomes so significant that it interferes with gains made during school year.
a) Did the student experience severe regression on current, annual IEP goal(s) and/or objective(s) following
extended school breaks? _____ Yes _____ No
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b) If no, precede to # 3 Predictive Factor Data.
If yes, did the student require an unreasonably long recoupment time to regain previously learned skills?
_____ Yes
_____ No
c) If no, precede to # 3 Predictive Factor Data.
If yes, list current, annual IEP goal(s) and/or objective(s) on which the student experienced severe
regression and document length of recoupment time:
3. Describe Predictive Factor Data to determine whether or not there is potential for severe regression and
recoupment on current, annual IEP goal(s) and/or objective(s) during extended breaks and list Source of
Evidence. Address predictive factor(s) below only when applicable
______________________________________________________________________________________________________
3a. Critical Skill
Describe how the student’s critical skills have the potential for severe regression and recoupment on
current, annual IEP goal(s) and/or objective(s) during extended breaks.
Note: Critical skills represent knowledge or performance essential to the progress of the student and are different for
every student. Identification of a critical skill does not, in and of itself, establish the need for ESY services .
Source of Evidence: _________________________________________________
______________________________________________________________________________________________________
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3b. Nature and Severity
Describe how the nature or severity of the student’s disability has the potential for severe regression and
recoupment on current, annual IEP goal(s) and/or objective(s) during extended breaks.
Source of Evidence: _________________________________________________
______________________________________________________________________________________________________
3c. Behavior
Describe how the student’s behavior has the potential for severe regression and recoupment on current,
annual IEP goal(s) and/or objective(s) during extended breaks. If applicable, provide Behavior Intervention
Plan (BIP) information and related data collection.
Source of Evidence: _________________________________________________
______________________________________________________________________________________________________
3d. Vocational Needs
Describe student’s ongoing vocational instruction needed in order to avoid severe regression and
recoupment on current, annual IEP goal(s) and/or objective(s) during extended breaks.
Source of Evidence: _________________________________________________
______________________________________________________________________________________________________
3e. Other Relevant Factors
Describe other relevant factors that present a risk of severe regression and recoupment on current, annual
IEP goal(s) and/or objective(s) during extended breaks.
Source of Evidence: _________________________________________________
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4. Summarize IEP Team Meeting Discussion on regression/recoupment and predictive factor data.
5. Summary of Determination
Based on the body of evidence, without continued special education and/or related services, will the
student experience a severe regression and recoupment on current annual, IEP goal(s) and/or objective(s)
that will significantly jeopardize:
(a) educational benefits accrued by the student during the regular school year, and
(b) meaningful benefit from a Free and Appropriate Public Education?
_____ Yes (continue)
_____ No (stop)
If Yes, Source of Evidence: _________________________________________________
6. List EYS Goal(s)
List current, annual IEP goal(s) that need to be addressed through ESY services.
Note: ESY services are not intended to address newly developed goals and objectives, or to replicate full
day services during the school year.
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7. Describe Potential Supports
______________________________________________________________________________________________________
7a. Home/Community Activities
Describe any family available resources that may address potential for severe regression and recoupment
on current, annual IEP goal(s) and/or objective(s) during extended breaks.
7b. Peer Opportunities
Describe opportunities student will have to interact with peers without disabilities during extended breaks
that may assist student in avoiding severe regression and recoupment on current, annual IEP goal(s).
8. Detail EYS Services
NOTE: ESY services can be provided in a variety of settings (e.g., home, school, community). A school system is not
required to create new programs as a means of providing ESY services in inclusive programs. The IEP team may
determine that Potential Supports (i.e. Home/Community Activities, Peer Opportunities) are sufficient to address ESY
service needs.
Type: ___________________________________________________________________________________________
Location: _________________________________
Frequency: ____________________________________
ESY services may be provided through:
 School-based program
 Week of intensive review prior to the beginning of the
 Daily individual or small group instruction
 Intensive short-term instruction at various points in break
school year
to prevent regression
 Cooperative program with outside agency
 Family-planned community or home activities
 Related-service(s) in community program
 Related-services (e.g., therapy services, transportation,
supplemental aids and services)
 Consultation with job coach
 Other
 Home-based program (e.g., parent
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training)
List names, positions and dates for IEP team members who provided information for this
document:
Name/Signature
Position
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Date
May be reproduced