2016 EXTENDED SCHOOL YEAR (ESY) AND SUMMER SERVICES INFORMATION WORKSHEET TO BE COMPLETED ONLY FOR STUDENTS REQUIRING SERVICES LISTED ON PAGE 1 (DUE DATE MAY 13, 2016) – ESY / Summer School Site: ________________________________ WL#________ Date Submitted ___________________ Current School: _____________________ WL#________ Contact: _________________________ Phone: ______________ Complete pages 1-5 for students with disabilities attending ESY or Summer Services that need supplementary or related services which requires special planning and preparation. Complete a separate form for each school site. ESY/Summer School sites providing services to their current students must also complete this chart. Please email or fax completed pages to the ESE Service Center the District Office and by May 13, 2016 so that necessary preparations can be made. Use the codes listed on page 2 to complete the equipment and assistive technology columns, as needed. Grade Level Primary Specialized ITN ITN Orient. & Adaptive Assistive Student Name ID # NURS (2016-2017) Except. Food Prep. VI DHOH Mobility Equipment Tech. 1 2 3 4 5 6 7 8 9 10 11 12 ADAPTIVE EQUIPMENT AND ASSISTIVE TECHNOLOGY CODES REFERENCE PAGE 2 SPECIAL FOOD PREPARATION REQUEST COMPLETE PAGE 3 ASSISTIVE TECHNOLOGY TRANSFER REQUEST COMPLETE PAGE 4 EQUIPMENT TRANSFER REQUEST COMPLETE PAGE 5
2016 EXTENDED SCHOOL YEAR (ESY) AND SUMMER SERVICES INFORMATION WORKSHEET TO BE COMPLETED ONLY FOR STUDENTS REQUIRING SERVICES LISTED ON PAGE 1 (DUE DATE – MAY 13, 2016) ESY / Summer School Site: ________________________________ WL#________ Date Submitted ___________________ Current School: _____________________ WL#________ Contact: _________________________ Phone: ______________ Complete pages 1-5 for students with disabilities attending ESY or Summer Services that need supplementary or related services which requires special planning and preparation. Complete a separate form for each school site. ESY/Summer School sites providing services to their current students must also complete this chart. Please email or fax completed pages to the ESE Service Center and the District Office by May 13, 2016 so that necessary preparations can be made. Use the codes listed on page 2 to complete the equipment and assistive technology columns, as needed. Student Name ID # Grade Level (2016-2017) Primary Except. NURS Specialized Food Prep. ITN VI ITN DHOH Orient. & Mobility Adaptive Equipment Assistive Tech. 1 2 3 4 5 6 7 8 9 10 11 12 ADAPTIVE EQUIPMENT AND ASSISTIVE TECHNOLOGY CODES REFERENCE PAGE 2 SPECIAL FOOD PREPARATION REQUEST COMPLETE PAGE 3 ASSISTIVE TECHNOLOGY TRANSFER REQUEST COMPLETE PAGE 4 EQUIPMENT TRANSFER REQUEST COMPLETE PAGE 5
ESY_info_worksheet16.docx