Extended School Year Regression/Recoupment Documentation Sheet

Student’s Name: Suzy Sample Date of Birth: 2-28-98 Date Submitted: 5-15-10 School: Sunshine Elementary Case Manager: Ms. ESE Teacher Program/Grade: Autism/3 rd

Regression refers to a significant decline in the performance of a skill or acquired knowledge, specified in the annual goals as stated in the student’s T/IEP, that occurs during a break in instruction. Recoupment refers to a student’s ability to regain the performance of a skill or acquired knowledge to approximately the same level of performance demonstrated prior to the break in instruction.

Documentation of regression and recoupment times following significant school breaks SUMMER BREAK (SuB), WINTER BREAK (WiB) and SPRING BREAK (SpB) and/or other extended absences without hospital/homebound services (document reason, e.g., surgery, etc.). Data must be collected for each break in service with a minimum of four essential objectives addressed. This documentation must be submitted to your administrator when recommending ESE-ESY for the student.

Reason for Annual (T) IEP Goal Level of Function Before Level of Function After Strategies Used/Recoupment Break/Number Break/Date Gathered Break/Date Gathered Time (number of days it took to of Days regain skill)

SuB 40 Student will …..Dolch words 16 out of 20 words 6/1/ 5 out of 20 words 8/30/ Daily flash cards 35 days 2009 2009 Bingo Dolch word game days

WiB 10 Student will …..safety signs Recognizes 11/30/ Recognizes safety signs 1/10/ Flash cards 17 days 9 out of 10 (90%) 2009 2 out of 10 (20%) 2010 Peer tutor days

WiB 10 Student will ….transition with Observed appropriate 11/30/ Observed appropriate 1/10/ Social Story 27 days out inappropriate behaviors. transitions 8 out of 10 2009 transitions 1 out of 10 2010 Peer modeling days opportunities (80%) opportunities (10%) WiB 10 Student will ….answer yes/no Observed appropriate 11/30/ Observed appropriate 1/10/ Visuals 5 days questions answers 8 out of 10 2009 answers 4 out of 10 2010 Teacher modeling days opportunities (80%) opportunities (40%) SpB 5 Student will …..Dolch words 16 out of 20 words 3/25/ 16 out of 20 words 4/10/ Parent took home flash n/a days 2010 2010 cards and worked daily with child SpB 5 Student will …..safety signs Recognizes 3/25/ Recognizes safety signs 4/10/ No regression noted n/a days 9 out of 10 (90%) 2010 9 out of 10 (90%) 2010

SpB 5 Students will ….transition with Observed appropriate 3/25/ Observed appropriate 4/10/ Social story 10 days out inappropriate behaviors. transitions 8 out of 10 2010 transitions 5 out of 10 2010 Peer modeling days opportunities (80%) opportunities (10%) SpB 5 Student will ….answer yes/no Observed appropriate 3/25/ Observed appropriate 4/10/ Visuals 5 days questions answers 10 out of 10 2010 answers 8 out of 10 2010 Teacher modeling days opportunities (100%) opportunities (80%) Extended School Year Regression/Recoupment Documentation Sheet