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Data!Collection!for!Determination!of!!ESY!Goals!
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Student!Name:! !
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Student!ID:!!
ESY!School!Year:!!
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Dates!of!Break!from!Instruction:!! !
From:!! ________________! to:!_________________!
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Dates!Instruction!Re=implemented:!
From:!!!!________________!! to:!_________________!
Directions:!
1. List!no!more!than!2=3!IEP!goals!under!box!#1.!Goals!may!be!abbreviated!but!the!measure!statement!should!be!evident.!
2. Record!in!box!#2!the!students!progress!prior!to!the!break!in!instruction.!Goals!that!are!new!and!do!not!have!a!sufficient!amount!of!data!record!IT!(insufficient!
time).!
3. Record!in!box!#3!progress!when!instruction!was!re=implemented.!
4. Record!in!box!#4!percentage!of!recoupment!following!re=implementation!of!instruction.!Mark!yes!if!goal!is!eligible!for!ESY.!Mark!no!if!goal!is!not!eligible!for!
ESY.!
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#1:!IEP!Goal.!Indicate!no!more!than!2=3! #2:!Current!rate!of!progress!prior!to!=
#3!Current!rate!of!progress!with!re=
#4:!Indicate!%!recoupment!
goals!
break!in!instruction!
implementation!of!instruction.!
Indicate!ESY!eligibility!
Indicate!percentage!of!regression!
Example:)Jimmy)will)read)a)list)of)10)
Example:)As)of)12/21/12,)Jimmy)reads)a)
Example:)As)of)1/03/13,)Jimmy)reads)a)
Example:)As)of)1/16/13,)Jimmy)reads)a)
sight)words)with)80%)accuracy.)
list)of)10)sight)words)with)70%)accuracy.)) list)of)10)sight)words)with)50%)accuracy)) list)of)10)sight)words)with)60%)
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accuracy)
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Eligible!for!ESY:!!!!Yes!!!!!!!No!
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Regression!Recoupment:!!Yes!!!No!
Percent!regression:)20%)
Percent!recoupment:!"10%!
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Self!Sufficiency:!Yes!!!!!!No!
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Unique!Needs:!!!!Yes!!!!!!No!
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Eligible!for!ESY:!!!!Yes!!!!!!!No!
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Percent!regression:!
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Regression!Recoupment:!!Yes!!!No!
Percent!recoupment:!!
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Self!Sufficiency:!Yes!!!!!!No!
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Unique!Needs:!!!!Yes!!!!!!!No!
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Percent!regression:!

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Percent!regression:!

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Eligible!for!ESY:!!!!Yes!!!!!!!No!
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Regression!Recoupment:!!Yes!!!No!
Percent!recoupment:!!
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Self!Sufficiency:!Yes!!!!!!No!
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Unique!Needs:!!!!Yes!!!!!!!No!
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Eligible!for!ESY:!!!!Yes!!!!!!!No!
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Regression!Recoupment:!!Yes!!!No!
Percent!recoupment:!!
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Self!Sufficiency:!Yes!!!!!!No!
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Unique!Needs:!!!!Yes!!!!!!!No!