BROWNSVILLE INDEPENDENT SCHOOL DISTRICT
RECOMMENDATION FOR EXTENDED SCHOOL YEAR (ESY)
Special Services
2467 Price Road
Brownsville, Texas 78521
Name: ______
Last First MI
Student ID:______DOB: ______Age: ______Grade: ______
School: ______Teacher: ______
Instruction: Recommendation/approval of a student to receive Extended School Year (ESY)
occurs in several steps. Below are the steps to follow after fully completing this
form. All information MUST be completed before being considered for ESY.
(A) The school completes this form along with copies of the evidence documenting the need for
ESY and submits it to the campus diagnostician.
(B) The diagnostician, speech therapist, and/or related service(s) person will review the data and
Determine if an Extended School Year ARD is needed. Determination is based on the evidence of documentation provided by formal/informal evaluations, recorded observations by parents and school personnel, and progress reports. This form is than returned to the student’s special education teacher indicating if there is a need for an ARD meeting to address ESY services.
(C) ESY will be addressed at the ARD meeting. If ESY is determined appropriate, than the
following forms will be submitted to the Department of Special Services.
(1) Recommendation for ESY (this form)
(2) ESY Composite and Checklist (ESY Comp/Checklist 102)
(3) Copy of Extended School Year Services ARD/IEP Supplement
(5) Copy of SPED Transportation
(6) Copy of the Current IEP Goals and Objective.
1. Evidence (such as, but not limited to, formal and informal evaluation results, including recorded
observations by parents and school personnel, and progress reports) which has been determined to demonstrate the need for ESY: INDICATE ALL THAT APPLY AND ATTACH COPIES OF EVIDENCE.
_____ Progress Reports from: ( ) teachers, ( ) parents, ( ) school personnel
_____ Observations and/or documentation of specific skills lost during extended periods of time
and how long it took the student to recoup those skills:
Beginning of school year ______
(Time to recoup)
Holidays, breaks, etc. ______
(Time to recoup)
______Criterion referenced checklist(s) Information evaluation Brigance (developmental)
2. What is the nature and severity of the student’s disability?
______
______
______
______
3. What are the critical areas addressed in the current IEP for which the provision of ESY is
specifically needed to maintain the existing skills so that one or more of the following will NOT occur: (Occurrence during the first eight weeks of the next regular school year)
( ) placement in a more restrictive instructional arrangement.
( ) significant loss of acquired skills necessary for the student to appropriately progress in the
general curriculum.
( ) significant loss of self-sufficiency in self-help skill areas as evidence by an increase in the
number of direct service staff and/or amount of time required to provide special education or
related services.
( ) loss of access to community-based independent living skills instruction or an independent
living environment provided by non-educational sources as a result of regression in skills.
( ) the loss of access to on-the-job training or productive employment resulting in regression of
skills.
ESY DOCUMENTED EVIDENCE PRESENTED FOR APPROVAL BY (Instructional Personnel):
______
Print Name Signature Date
______
Print Name Signature Date
THERE IS SUFFICIENT DOCUMENTATION FOR AN ARD COMMITTEE TO ADDRESS
ESY SERVICES FOR: ( ) INSTRUCTION ( ) SPEECH THERAPY
( ) PHYSICAL THERAPY ( ) OCCUPATIONAL THERAPY
______
Campus Diagnostician (Print Name) Signature Date
______
Speech Therapist (Print Name) Signature Date
______
Occupational Therapist (Print Name) Signature Date
______
Physical Therapist (Print Name) Signature Date
Revised ESY Recommend 101 (2/13/08)