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/3rd

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 Break/Number
of Days / Annual (T) IEP Goal / Level of Function Before Break/Date Gathered / Level of Function After Break/Date Gathered / Strategies Used/Recoupment Time (number of days it took to regain skill)
SuB / 40
days / Student will …..Dolch words / 16 out of 20 words / 6/1/
2009 / 5 out of 20 words / 8/30/
2009 / Daily flash cards
Bingo Dolch word game / 35 days
WiB / 10 days / Student will …..safety signs / Recognizes
9 out of 10 (90%) / 11/30/
2009 / Recognizes safety signs
2 out of 10 (20%) / 1/10/
2010 / Flash cards
Peer tutor / 17 days
WiB / 10 days / Student will ….transition with out inappropriate behaviors. / Observed appropriate transitions 8 out of 10 opportunities (80%) / 11/30/
2009 / Observed appropriate transitions 1 out of 10 opportunities (10%) / 1/10/
2010 / Social Story
Peer modeling / 27 days
WiB / 10 days / Student will ….answer yes/no questions / Observed appropriate answers 8 out of 10 opportunities (80%) / 11/30/
2009 / Observed appropriate answers 4 out of 10 opportunities (40%) / 1/10/
2010 / Visuals
Teacher modeling / 5
days
SpB / 5
days / Student will …..Dolch words / 16 out of 20 words / 3/25/
2010 / 16 out of 20 words / 4/10/
2010 / Parent took home flash cards and worked daily with child / n/a
SpB / 5
days / Student will …..safety signs / Recognizes
9 out of 10 (90%) / 3/25/
2010 / Recognizes safety signs
9 out of 10 (90%) / 4/10/
2010 / No regression noted / n/a
SpB / 5 days / Students will ….transition with out inappropriate behaviors. / Observed appropriate transitions 8 out of 10 opportunities (80%) / 3/25/
2010 / Observed appropriate transitions 5 out of 10 opportunities (10%) / 4/10/
2010 / Social story
Peer modeling / 10 days
SpB / 5 days / Student will ….answer yes/no questions / Observed appropriate answers 10 out of 10 opportunities (100%) / 3/25/
2010 / Observed appropriate answers 8 out of 10 opportunities (80%) / 4/10/
2010 / Visuals
Teacher modeling / 5
days