<p> Extended School Year Regression/Recoupment Documentation Sheet</p><p>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 </p><p>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.</p><p>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.</p><p>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)</p><p>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</p><p>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</p><p>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</p><p>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</p>