2011 EXTENDED SCHOOL YEAR (ESY) SERVICES& SUMMER SERVICES PROGRAM (SSP)

INFORMATION WORKSHEET

TO BE COMPLETED FOR STUDENTS WITH SUPPLEMENTARY OR RELATED SERVICES(DUE MAY 20, 2011)

ESY Site: ______WL#______Date Submitted: ______

Current School: ______WL#______Contact: ______Phone: ______

Complete pages 1-5 for ESY students that require any of the special services listed or other services that would require special planning by the ESY site. Complete a separate form for each ESY site. Open ESY sites providing services to their current students must also complete this chart. Please email or fax completed pages to your Region SPED Department and the District Office by May 20, 2011 so that necessary preparations can be made. Refer to page 2 for *codes and contact information.

Student Name / ID # / Grade Level
(2011-2012) / Primary Except. / NUR / RESP / Food Prep. / ITN
VI / ITN
D/HH / Orient. & Mobility / Para Assistance* / Adaptive Equipment* / Assistive
Tech. *
1
2
3
4
5
6
7
8
9
10
PARA ASSISTANCE,ADAPTIVE EQUIPMENT AND AT CODES / COMPLETE PAGE 2
SPECIAL FOOD PREPARATION REQUEST / COMPLETE PAGE 3
EQUIPMENT TRANSFER REQUEST / COMPLETE PAGE 4
ASSISTIVE TECHNOLOGY TRANSFER REQUEST / COMPLETE PAGE 5

2011 EXTENDED SCHOOL YEAR (ESY) SERVICES & SUMMER SERVICES PROGRAM (SSP)

INFORMATION WORKSHEET

PARA ASSISTANCE, ADAPTIVE EQUIPMENT, AND ASSISTIVE TECHNOLOGY CODES

PARA ASSISTANCE / CODES / SPECIFY THE SPECIFIC STUDENT NEEDS FROM THE IEP*
Academic Support* / ACSU / *
Danger to Self/Others* / SAFE / *
Feeding* / FEED / *
Positioning* / POS / *
Toileting* / TT / *
Transitioning* / MOVE / *
Other* ______/ OTH / *
Other* ______/ OTH / *
ADAPTIVE EQUIPMENT / CODES / SPECIFY* / ASSISTIVE TECHNOLOGY / CODES / SPECIFY*
Changing Table / CT / Amplification System / AS
Lift* / LIFT / * / Battery/Electrical Access Device / BEAD
Privacy Screen / PS / Computer Access Device / CAD
Adaptive Chair / AC / Vision Enhance Equipment / VEE
Adaptive Toilet / AT / Voice Output Device / VOCD
Adaptive Toilet Seat / ATS / Writing Access Device / WAD
Adaptive Feeding Equipment* / AFE / * / Other* ______/ OTH / *
Prone Stationary Stander / PSS
Supine Stationary Stander / SSS
Positioning Mat / PM
Other* ______/ OTH / *

Note: Complete page 4 for transfer of equipment.Note: Complete page 5 for transfer or coordination of AT.

REGION & DISTRICT OFFICE CONTACT INFORMATION

OFFICE / NAME / TITLE / EMAIL / FAX
Region I / Alfredia Robinson / SPED Instructional Supervisor / / 305-953-5450
Region II / Kate Cadieux / SPED Instructional Supervisor / / 305-528-2801
Region III / Arlene Exelbert / SPED Instructional Supervisor / / 305-889-3502
Region IV / Kathy Maguire / SPED Instructional Supervisor / / 305-273-8178
Region V / Helene Chait / SPED Instructional Supervisor / / 305-252-6745
ETO / Viviana Arias / SPED Instructional Supervisor / / 305-523-0673
Div. of Special Educ. / Mary Paz / SPED Instructional Supervisor / / 305-995-1760

2011 EXTENDED SCHOOL YEAR (ESY) SERVICES & SUMMER SERVICES PROGRAM (SSP)

INFORMATION WORKSHEET

SPECIAL NEEDS MEALS (DUE MAY 20, 2011)

Complete this page for any student with a disability requiringspecialized food preparation for ESY or SSP.

ESY SCHOOL LOC # / ESY
SCHOOL NAME / STUDENT
NAME / STUDENT
ID / GRADE
(2011-2012) / SPECIALIZED FOOD PREPARATION (specify)

2011 EXTENDED SCHOOL YEAR (ESY) SERVICES & SUMMER SERVICES PROGRAM (SSP)

INFORMATION WORKSHEET

EQUIPMENT TRANSFER (DUE DATE – MAY 20, 2011)

Complete this page if needed equipment is not available at the assigned ESY/SSP site and is required for a student(s) to access SSP or ESY.

Equipment transfer(s) must be coordinated with the ESY/SSP receiving school(s) in collaboration with Region and District SPED Offices.

EQUIPMENT THAT NEEDS TO BE TRANSFERED* / DESCRIPTION OF EQUIPMENT / PROPERTY CONTROL NUMBER / NUMBER OF STUDENTS REQUIRING THIS EQUIPMENT
Changing Table
Lift
Privacy Screen
Adaptive Chair
Adaptive Toilet
Adaptive Toilet Seat
Adaptive Feeding Equipment
Prone Stationary Stander
Supine Stationary Stander
Positioning Mat
Other
LOCATION OF EQUIPMENT IN THE BUILDING* / PICK-UP LOCATION SCHOOL NAME AND LOCATION # / PICK-UP LOCATION CONTACT NAME AND PHONE / DROP -OFF
SCHOOL NAME AND LOCATION # / DROP-OFF CONTACT NAME AND PHONE

2011 EXTENDED SCHOOL YEAR (ESY) SERVICES & SUMMER SERVICES PROGRAM (SSP)

INFORMATION WORKSHEET

ASSISTIVE TECHNOLOGY (DUE MAY 20, 2011)

Complete this page for any student with a disability requiring the transfer or coordination of Assistive Technology in order to access ESY services or the SSP. Assistive Technology transfers must be coordinated with the ESY receiving school(s) and the Region Office. AT that requires pick-up from S&D must be coordinated with the District SPED Office.

Name of Student: ______ID#: ______

Current School Site: ______Mail Code: ______

ESY or SSP Site: ______Mail Code: ______

□ Summer Services Program (SSP) □ ESY Services (dates of service: ______-______if other than 06/23/11 - 07/21/11)

ASSISTIVE TECHNOLOGY REQUIRED / DESCRIPTION OF EQUIPMENT / PROPERTY CONTROL # / STUDENT NAME / DROP-OFF CONTACT NAME
Amplification System
Battery/Electrical Access Device
Computer Access Device
Vision Enhance Equipment
Voice Output Device
Writing Access Device
Other: ______
Other: ______

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