MADISONMETROPOLITANSCHOOL DISTRICT

DEPARTMENT OF EDUCATIONAL SERVICES - SPECIAL EDUCATION

Student / Student # / Date of Birth / Gender / Grade / School of Attendance
M F

PROJECTION WORKSHEET FOR CONSIDERATION OF ESY SERVICES

FOR REGRESSION/RECOUPMENT

DUE by Feb 14, 2014

Staff member submitting form:

Case manager: ______Phone number: ______

NOTE: A separate worksheet must be completed for each area of need (reading, math, language, motor skills, etc.) considered for each student.

1. In reviewing the current/finalized IEP, please indicate the goal number and area of need as listed on that IEP for which you are considering ESY services:

Goal No.
Area of Need: (as listed on the IEP)

2. Please list the weekly amount of time that is listed on the IEP Summary of the current finalized IEP to carry out the above goal:

Name of Service (Check one box ONLY) / CC SL OT PT Other (list)
No.of hours/minutes per week in IEP currently:
Please list 50% of those services here:
(Hours for consideration of ESY services cannot exceed these hours without coordinator approval.) If the student’s IEP does not currently list services on the IEP Summary for this area of need, you do not have the necessary information to support discussing ESY services.

3. Please list the functioning level of this goal as of May, 2013. List specific supporting assessment information such as standardized test scores, rating inventories, informal checklists, progress monitoring, observations, etc.

If assessment information is not available STOP, you do not have the necessary information to support discussing ESY services.

4. Please list the functioning level of this goal as of Nov.8, 2013. List specific supporting assessment information such as standardized test scores, rating inventories, informal checklists, progress monitoring, observations, etc.

If assessment information is not available STOP, you do not have the necessary information to support discussing ESY services.

5. Is this student new to ESY or is this a new area of ESY for this student?Yes NoIf no, skip to question #7.

If yes, are you considering services in a new area of need (or new to ESY) due to regression/recoupment or critical stage?

Regression/Recoupment: To prevent severe regression (i.e., substantial loss) of acquired skills during an interruption in instruction which may then require a significant time for recoupment of those skills (i.e., instructional time which exceeds 9 weeks to reestablish skills) If Regression/Recoupment, continue on to Question #6.

Critical Stage: Critical stage ESY projections cannot be submitted before March 18th. The form will be posted on the ESY website at that time. Critical stage is when a break in instructional programming would result in a significant loss of progress made toward the acquisition of a critical or emerging skill. Skills are defined as those basic abilities which enable a student to function independently of others. These may include, but are not limited to self help skills, communication skills, vocational skills and functional academic skills.

6. If this is a student new to ESY or this is a new area of ESY and you are considering services for regression/recoupment, is there a discrepancybetween the assessment information in items 3 and 4 on the first page(loss of skill from May that wasn’t regained by November)?

Yes.You have the supporting information to go forward with considering ESY for this student. Skip to question #8.

No. The student has not demonstrated a significant regression to support further discussions surrounding the need for ESY services.

7. Is thisan area of need for which the student had services for ESY last summer? Yes No

If yes, is there a discrepancy between the assessment information in items 3 and 4 on the first page (loss of skill from May that wasn’t regained by November)?

Yes

The ESY services provided last summer in this area of need did not sufficiently prevent the student from further regression. The team should look to see if the student was present for services last summer. If attendance was an issue, services will need coordinator approval to be considered. If the student was present, the team should consider if the student will benefit from continued ESY services. A meeting should be scheduled to further discuss ESY services. Continueon to Question #8.

No

The ESY services provided last summer in this area of need sufficiently prevented the student from further regression. The team may consider offering similar services. Continueon to Question #8.

8. While ESY serves a specific purpose related to regression/recoupment or critical stage, we are exploring possible opportunities for enrichment. From your perspective, can you estimate how much supportthe student would need for the following, separate from specific ESY services as projected above? This will help us estimate staff needs.

Enrichment classes (science, art, etc): independently with minimal support requires maximal support

Language arts class: independently with minimal support requires maximal support

Math class: independently with minimal support requires maximal support

SREC/afternoon recreation program: independentlywith minimal support requires maximal support

(Independently means no support needed. Minimal support means an SEA checking in, minor modifications, or an SEA in classroom working with several students. Maximal support means a staff person needs to be there for support at all times.)

Please note: If you have been stopped at any point in this process and have questions or concerns you may contact your area coordinator for further discussion.

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