Sheffield City Schools

Extended School Year (ESY) Data Collection Form

Student Name ______Date of Birth ______School Year ______

School ______Grade _____ Goal Area ______Prepared By ______

IEP Goal:
End of Previous School Year Baseline Level (collected last 6 weeks of school)
August Skill Level (collected during first 2 weeks of school) / Was there regression over the summer? [ ] YES [ ] NO
If YES – date recouped after summer break
December Skill Level (collected within 2 weeks before Christmas break)
January Skill Level (collected within 1 week after Christmas break) / Was there regression over Christmas break? [ ] YES [ ] NO
If YES - date recouped after Christmas break
Spring Skill Level (collected within 2 weeks before Spring break)
Post Spring Break Skill Level (collected within 1 week of returning from Spring break) / Was there regression over Spring break? [ ] YES [ ] NO
If YES – date recouped after Spring break
  1. Did the student show regression over breaks? [ ] YES [ ] NO
  2. After 9 weeks, did the student recoup those skills? [ ] YES [ ] NO [ ] N/A
  3. Were the areas of regression considered “critical skills”? [ ] YES [ ] NO [ ] N/A

If the student regressed and did NOT recoup those skills after 9 weeks of instruction AND the skills were critical skills – then the student may qualify for ESY.

Areas to be addressed during ESY: ______

Specific skill(s) to be addressed during ESY: ______

Present Level of Performance: ______

______

Materials currently used to teach this skill: ______

List any special concerns you are aware of regarding this student (health plan, BIP, etc.) ______

______

Parent /Guardian Contact Information (please provide accurate numbers so that parents can be notified of service days/times:

______

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