Extended School Year Services Application Process and Requirement Details

 
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OFFICE OF SPECIAL
EDUCATION
EXTENDED SCHOOL YEAR
SERVICES (ESY)
 
EXTENDED SCHOOL
YEAR SERVICES
APPLICATION
 
Extended School Year
 
Extended School Year (ESY)
Means special education and related
services that
 Are provided to a child with a disability
»
 Beyond the normal school year of the
public agency;
»
In accordance with the child’s IEP; and
»
At no cost to the parents of the child
 
 
 
 
 
 
9/30/2024
 
4
 
EXTENDED SCHOOL YEAR
 
The Individualized Education Program
(IEP) Committee may begin making
ESY decisions no earlier than January
15
th
 of each year.
ESY decisions should be completed by
April 15
th
 of each year.
 
 
 
 
 
 
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5
 
APPLICATION PROCESS
 
Packets will be available March 2015
D
istricts 
must
 submit all of the required forms
Cover Page or Non-Participation Assurance Form
Projected Budget Summary
Projected Budget Narrative
ESY Private Placement
ESY Roll
ESY Service Provider Listing
 
 
 
 
 
 
9/30/2024
 
6
 
Non-Participation Form - Q-1
 
Non-Participation Assurance Form
Signed in blue ink (good practice to assure
original copies) and submitted by the due
date
Must be on file in the Office of Special
Education
 
 
 
 
 
 
 
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9/30/2024
 
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Cover Page - O-1
 
Cover Page
Signed in blue ink (good practice to assure
    original copies) and submitted by due date
Number of students served by disability category
should equal the R-4 ESY Roll
Indicate the beginning and ending dates for the
district’s ESY program
Indicate the beginning and ending times
Estimated overall totals should match the R-1
 
 
 
 
 
 
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9/30/2024
 
10
 
COVER PAGE
EXTENDED SCHOOL YEAR APPLICATION
 SUMMER 2015 (SY2014-2015)
 
ESY PROJECTED BUDGET SUMMARY
 
Projected Budget Summary
Totals listed must match the amounts listed
on the Cover Page (O-1)
Totals listed must match the respective
budget pages
Only list the total amounts
Include district name on all forms
 
 
 
 
 
 
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9/30/2024
 
12
 
ESY PROJECTED BUDGET NARRATIVE
SUMMER 2015 (SY2014-2015)
 
Salaries/Fringes
List all district personnel providing/participating in ESY in alphabetical
order
District personnel listed here are also found on the Service Provider
Listing (R-5)
Certified district personnel listed are also found on the ESY Roll (R-4)
Names used should match the license being provided
Only list the total amount
Do not show fringes amount and salary amount; only need one figure
Total amount matches the Cover Page (O-1) and the Projected Budget
Summary Page (R-1)
 
 
 
 
 
 
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14
 
R-2A
 
ESY
PROJECTED BUDGET NARRATIVE
SUMMER 2015 (SY2014-2015)
Describe the budget items for each category. Documentation should be on file in the district to justify the necessity and reasonableness of each item. These
pages may be reproduced as needed.
 
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15
 
ESY
PROJECTED BUDGET NARRATIVE
SUMMER 2015 (SY2014-2015)
 
Describe the budget items for each category. Documentation should be on file in the district to justify the necessity and reasonableness of each item. These pages
may be reproduced as needed.
 
R-2A
 
ESY PROJECTED BUDGET NARRATIVE
SUMMER 2015 (SY2014-2015)
 
Travel/Transportation
Indicate travel costs for itinerant teachers
Indicate travel costs for parents of students in ESY
Indicate transportation cost of district buses
DO NOT include transportation cost of students in private
placement being transported by the facility
Do include the transportation cost of students in private
placement being transported by district buses
Total amount matches the Cover Page (O-1) and the
Projected Budget Summary Page (R-1)
 
 
 
 
 
 
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9/30/2024
 
17
 
R-2B
 
ESY
PROJECTED BUDGET NARRATIVE
SUMMER 2015 (SY2014-2015)
 
9/30/2024
 
18
 
R-2B
 
ESY
PROJECTED BUDGET NARRATIVE
SUMMER 2015 (SY2014-2015)
 
ESY PROJECTED BUDGET NARRATIVE
SUMMER 2015 (SY2014-2015)
 
Contractual Services
Indicate the cost of contractual service personnel to include
travel costs
List the names of Contractual Personnel
Contractual Personnel listed here should also be listed on
the ESY Roll (R-4) and the Service Provider Listing (R-5)
Total amount matches the Cover Page (O-1) and Projected
Budget Summary Page (R-1)
 
 
 
 
 
 
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9/30/2024
 
20
 
R-2C
 
ESY
PROJECTED BUDGET NARRATIVE
SUMMER 2015 (SY2014-2015)
 
9/30/2024
 
21
 
R-2C
 
ESY
PROJECTED BUDGET NARRATIVE
SUMMER 2015 (SY2014-2015)
 
ESY PROJECTED BUDGET NARRATIVE
SUMMER 2015 (SY2014-2015)
 
Materials/Supplies/Commodities
Provide an 
itemized listing 
of the items to
be purchased
Indicate the quantity, unit cost and extended
price
Equipment is not an allowable purchase
Total matches the Cover Page (O-1) and the
Projected Budget Summary Page (R-1)
 
 
 
 
 
 
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22
 
9/30/2024
 
23
 
ESY
PROJECTED BUDGET NARRATIVE
SUMMER 2015 (SY2014-2015)
 
9/30/2024
 
24
 
R-2D
 
ESY
PROJECTED BUDGET NARRATIVE
SUMMER 2015 (SY2014-2015)
 
ESY PROJECTED BUDGET NARRATIVE
SUMMER 2015 (SY2014-2015)
 
(Other)
Provide a clear description of what
“other” is
Total matches the Cover Page (O-1) and
the Projected Budget Summary Page
(R-1)
 
 
 
 
 
 
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9/30/2024
 
26
 
ESY
PROJECTED BUDGET NARRATIVE
SUMMER 2015 (SY2014-2015)
 
9/30/2024
 
27
 
ESY PROJECTED BUDGET NARRATIVE
SUMMER 2015 (SY2014-2015)
 
R-2E
 
PRIVATE
 PLACEMENT
 
ESY Private Placement
Initial Placement of Students
School District
»
Letter of Justification
»
ESY page of the IEP with signatures
»
Determination of Eligibility
Department of Human Services
»
Letter of Justification
»
ESY page of the IEP with signatures
»
Current Court Order
»
Determination of Eligibility
 
 
 
 
 
 
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PRIVATE
 PLACEMENT
 
ESY Private Placement
Students placed after program begins
School District
»
Letter of Justification
»
ESY page of the IEP with signatures
»
Determination of Eligibility
Department of Human Services
»
Letter of Justification
»
ESY page of the IEP with signatures
»
Current Court Order
»
Determination of Eligibility
 
 
 
 
 
 
9/30/2024
 
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PRIVATE PLACEMENT
 
ESY Private Placement (R-3)
Daily rate used for calculation is $168.00
Transportation cost for private facilities is 82.00 unless you
negotiated a lower rate
Students listed here are also found on the ESY Roll (R-4)
Students listed here must have an approved Educable Child
application on file with a current eligibility ruling and a
current IEP
Transportation Cost for students in private placement is
listed here and 
NOT 
on the Projected Budget Narrative for
Travel/Transportation (R-2B) unless they are being
transported by district buses
 
 
 
 
 
 
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ESY PRIVATE PLACEMENT
SUMMER 2015 (SY2014-2015)
EDUCATIONAL
 
R-3
 
RESIDENTIAL
 
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Continued
 
ESY PRIVATE PLACEMENT
SUMMER 2015 (SY2014-2015)
TRANSPORTATION
 
EXTENDED SCHOOL YEAR ROLL
 
ESY Roll (R-4)
All columns must be completed
All students have a teacher’s name and/or a service
provider’s name
All personnel (teachers/service providers) can be found on
the Service Provider Listing (R-5)
All district personnel listed can be found on the Projected
Budget Narrative (R-2A)
All service providers can be found on the Projected Budget
Narrative (R-2C)
Justification for placement must match the IEP page
 
 
 
 
 
 
 
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9/30/2024
 
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R-4
 
ESY
STUDENT ROLL
SUMMER 2015 (SY2014-2015)
 
List all students served in ESY 
(including those students in private placement)
. Complete form R-3 for students served through private
placement.
 
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35
 
R-4
 
ESY
STUDENT ROLL
SUMMER 2015 (SY2014-2015)
 
List all students served in ESY (
including those students in private placement - R-3)
.
 
Individualized Education Program Page
 
ESY Individualized Education Program Page
Required committee members are listed along with
their roles
Annual goals or Short Term Instructional
Objectives are listed to include goals for all related
services being provided
Date of meeting is listed
Criterion used matches the criterion on the ESY
Roll (R-4)
 
 
 
 
 
 
 
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37
 
 R-4A
 
EXTENDED SCHOOL YEAR SERVICES
 
Student’s Name:
 
                                                                                                                                              Summer Session:
 
W - 6
 
* Check if goal/objective is a transition activity. (Student age 16 – 20)
** Does not require signatures; this section is utilized only to document individuals present at the meeting.
 
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38
 
EXTENDED SCHOOL YEAR SERVICES
 
 R-4A
 
Student’s Name:
 
   Aubree Hicks                                                                                                               Summer Session:  2015
 
W - 6
 
W - 6
 
SERVICE PROVIDER LISTING
 
Projected Service Provider Listing (R-5)
All personnel are listed
 Personnel on the Projected Budget Narrative (R-2A)
Personnel on the Projected Budget Narrative (R-2C)
Personnel on the ESY Roll (R-4)
Valid license numbers are listed and copies of
licenses are submitted to include private
school/facility personnel
 
 
 
 
 
 
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9/30/2024
 
40
 
R-5
 
ESY
PROJECTED SERVICE PROVIDER LISTING
SUMMER 2015 (SY2014-2015)
 
(Personnel listed on R-2A, R-2C, and R-4 are also listed here)
 
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R-5
 
ESY
PROJECTED SERVICE PROVIDER LISTING
SUMMER 2015 (SY2014-2015)
 
(Personnel listed on R-2A, R-2C, and R-4 are also listed here)
 
REIMBURSEMENT
 
Request for Reimbursement
Completed and signed in blue ink (good practice to
assure original copies)
ESY Private Placement Reimbursement form is
attached
Reason(s) for Exiting ESY program are given
Students’ names should be consistent
Transportation cost and transportation rate are provided
Educational costs are provided
Total number of days are provided
 
 
 
 
 
 
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9/30/2024
 
43
 
R-6
 
REQUEST FOR REIMBURSEMENT
 
EXTENDED SCHOOL YEAR
SUMMER 2015 (SY2014-2015)
 
DISTRICT NAME: ______________________________                                                                   DISTRICT CODE: _____________________
 
ACTUAL ESY EXPENDITURES
 
B
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As Superintendent of this district, I certify by my signature below and that to the best of my knowledge:
 
1.
This application for reimbursement represents the 
actual cost
 of operating ESY for the 2014 summer session. Sufficient documentation is available
for audit inspection.
2.
The students with disabilities served met the ESY criteria established in accordance with the Mississippi Department of Education regulations and
the educational services provided are specified in each student’s Individualized Education Program.
3.
No expenditure(s) which would have been incurred if there had not been ESY is (are) included for reimbursement. Documentation to support
expenditures is on file for audit inspection.
 
SUPERINTENDENT’S SIGNATURE (Blue Ink)                                                            DATE
 
Mail to:
Mississippi Department of Education
Office of Special Education
Post Office Box 771
                                                            Jackson, MS  39205-0771
 
DUE DATE: 
September 30, 2015
 
9/30/2024
 
44
 
R-6A
 
ESY PRIVATE PLACEMENT REIMBURSEMENT FORM
SUMMER 2015 (SY2014-2015)
 
Page ______ of ______
    
                                                  Revised 12/2014
 
TOP ISSUES
 
Teachers’ names do not match licenses
Licenses expire before program begins or ends
Licenses are not provided or License numbers are incorrect
Students’ and teachers’ names are not consistent
Names of service providers are not provided
ESY Private Placement Sheet not included with
Reimbursement
Additional information requested not included
Supervisor’s license not included for
OTAs/PTAs/BCaBA/RBT
Teachers are not properly endorsed or certified
 
 
 
 
 
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POINTS 
TO
 REMEMBER
 
Request for Reimbursement is due September 30,
2015
Request for Reimbursement received on or before
September 30
th
 will be processed for 50%
disbursement
Final Request for Reimbursement is due December
15, 2015
The remaining 50% and Request for Reimbursement
received after September 30
th
 will be processed for
payment in March and May of 2016
 
 
 
 
 
 
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46
 
TIMELINES
 
TIMELINES
 
January 2015
3
rd
 Period Educable Child Student Applications
January 9
Determination of ESY may begin
January 15
Personnel Snapshot Amendment
January 30
February 2015
3
rd
 Pay Period Educable Child Reimbursement
February 3
Positive Behavior Specialist (PBS) Reimbursement
February 12
Educational Interpreter (EI) Reimbursement
February 12
 
 
 
 
 
 
 
9/30/2024
 
48
 
TIMELINES
 
March 2015
Extended School Year Applications posted
March TBA
4
th
 Period Educable Child Student Applications
March 6
Final Draw for PBS and EI
March 31
April 2015
4
th
 Period Educable Child Reimbursement
April 2
Determination of ESY ends
April 15
 
 
 
 
 
 
9/30/2024
 
49
 
TIMELINES
 
April 2015
Justification for Maintenance of Effort
April TBA
Child Find Report
April 30
Extended School Year Applications
April 30
 
 
 
 
 
 
9/30/2024
 
50
 
TIMELINES
 
June 2015
Educable Child 5
th
 Pay Period Reimbursement
June 3
Educable Child School Approval Application
June 30
IDEA Part B and Preschool Application
June 30 (Wishful thinking) ☺
 
 
 
 
 
 
9/30/2024
 
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Slide Note

Good morning and welcome to last monthly Webinar for 2014. The webinar this morning will cover Personnel and an overview the fiscal toolkit. With this morning, I have Louis King and Mary Bobbitt. First let us cover some important announcements:

EDUCABLE CHILD:

Request for reimbursement forms were due yesterday, Dec 2.

Student applications will be due January 9, 2015

EXTENDED SCHOOL YEAR:

Final Date to submit your Request for Reimbursement is December 12.

All districts should receive a fax copy of the approved request for reimbursement. If you did not receive, you need to notify Roscoe by January 9.

PROJECT APPLICATIONS

We still have a few that have not been approved. We would like to have those approved before Christmas break. We thank you for responding to the corrections in a timely manner and for your patience as we work through the process with object codes and executive summary requirements.

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Learn about the Extended School Year (ESY) services application process, required forms, important deadlines for decision-making by the IEP Committee, and the Non-Participation Assurance Form. The application packets will be available in March 2015, and districts must submit all necessary forms including the Cover Page, Budget Summary, ESY Private Placement, and more. The IEP Committee can begin making ESY decisions no earlier than January 15th of each year and should complete them by April 15th. The Non-Participation Assurance Form must be signed and submitted by the due date. Check for detailed instructions and guidelines for the ESY services application process.

  • ESY services
  • Application process
  • IEP Committee
  • Non-Participation Assurance
  • Special education

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  1. Data and Fiscal Management Monthly Webinar January 6, 2015

  2. OFFICE OF SPECIAL EDUCATION EXTENDED SCHOOL YEAR SERVICES (ESY)

  3. EXTENDED SCHOOL YEAR SERVICES APPLICATION

  4. Extended School Year Extended School Year (ESY) Means special education and related services that Are provided to a child with a disability Beyond the normal school year of the public agency; In accordance with the child s IEP; and At no cost to the parents of the child 9/30/2024 4

  5. EXTENDED SCHOOL YEAR The Individualized Education Program (IEP) Committee may begin making ESY decisions no earlier than January 15th of each year. ESY decisions should be completed by April 15th of each year. 9/30/2024 5

  6. APPLICATION PROCESS Packets will be available March 2015 Districts must submit all of the required forms Cover Page or Non-Participation Assurance Form Projected Budget Summary Projected Budget Narrative ESY Private Placement ESY Roll ESY Service Provider Listing 9/30/2024 6

  7. Non-Participation Form - Q-1 Non-Participation Assurance Form Signed in blue ink (good practice to assure original copies) and submitted by the due date Must be on file in the Office of Special Education 9/30/2024 7

  8. NONPARTICIPATION ASSURANCE FORM School Year 2014-2015 School District: __________________________ As Superintendent of this district, I certify by my signature that there are no students eligible for Extended School Year Services based on IEP committee decisions. Documentation is on file supporting the decision that ESY services are not necessary. District Code: _____________ Superintendent s Signature (Blue Ink) Date Mail to: Mississippi Department of Education Office of Special Education P. O. Box 771, Suite 301 Jackson, MS 39205-0771 Attn: Division of Program Management DUE DATE: April 30, 2015 9/30/2024 8

  9. Cover Page - O-1 Cover Page Signed in blue ink (good practice to assure original copies) and submitted by due date Number of students served by disability category should equal the R-4 ESY Roll Indicate the beginning and ending dates for the district s ESY program Indicate the beginning and ending times Estimated overall totals should match the R-1 9/30/2024 9

  10. COVER PAGE EXTENDED SCHOOL YEAR APPLICATION SUMMER 2015 (SY2014-2015) B. STUDENT INFORMATION Disability Category Number Served Disability Category Number Served Autism (AU) Deaf/Blind (D/B) Developmentally Delayed (DD) Emotional Disability (EmD) Hearing Impairment (HI) Intellectual Disability (ID) [EMR,TMR,S/P] Language/Speech Impairment (S/L) Multiple Disabilities (MD) Orthopedic Impairment (OI) Other Health Impairment (OHI) Specific Learning Disability (SLD) Traumatic Brain Injury (TBI) Visually Impaired (VI) TOTAL C. Time Session Starts ____________________ Time Session Ends ________________ D. ASSURANCES As Superintendent of this district, I certify by my signature that: 1. This estimated budget for the ESY has been computed in accordance with Mississippi Department of Education regulations and guidelines. 2. All students with disabilities receiving an ESY meet criteria established in accordance with regulations and documentation is on file to support the decisions by the IEP Committee(s). 3. The specific skills to be maintained are clearly identified on the student's IEP, as requiring the provision of an ESY. 4. No expenditure(s) which would have been incurred if there were no ESY is (are) included in this budget. Documentation to support expenditures will be maintained on file for audit inspection. Superintendent s Signature (Blue Ink) E. ESTIMATED OVERALL COSTS: Beginning Date for ESY ________________ Ending Date for ESY ________________ Date APPROVAL: Salaries $ Travel $ MDE Staff Consultant Date Contractual services $ Director, Division of Program Management Date Materials/Supplies/ Commodities Private Placement $ Office Director, Fiscal Management Date $ PROJECTED APPROVAL AMOUNT: Other $ $_____________________________ Total 9/30/2024 10

  11. ESY PROJECTED BUDGET SUMMARY Projected Budget Summary Totals listed must match the amounts listed on the Cover Page (O-1) Totals listed must match the respective budget pages Only list the total amounts Include district name on all forms 9/30/2024 11

  12. R-1 ESY PROJECTED BUDGET SUMMARY SUMMER 2015 (SY2014-2015) DISTRICT NAME: ____________________________________________ Expenditures Expenditures must be thoroughly explained in the Budget Narrative. Amount Salaries, Wages, Fees and/or Fringes: $ Travel: $ Contractual Services: $ Materials/Supplies/Commodities: $ Private Placement: $ Other: (Utilities) $ Total Projected Budget: $ 9/30/2024 12

  13. ESY PROJECTED BUDGET NARRATIVE SUMMER 2015 (SY2014-2015) Salaries/Fringes List all district personnel providing/participating in ESY in alphabetical order District personnel listed here are also found on the Service Provider Listing (R-5) Certified district personnel listed are also found on the ESY Roll (R-4) Names used should match the license being provided Only list the total amount Do not show fringes amount and salary amount; only need one figure Total amount matches the Cover Page (O-1) and the Projected Budget Summary Page (R-1) 9/30/2024 13

  14. R-2A ESY PROJECTED BUDGET NARRATIVE SUMMER 2015 (SY2014-2015) Describe the budget items for each category. Documentation should be on file in the district to justify the necessity and reasonableness of each item. These pages may be reproduced as needed. Salaries/Fringes Use the section below to provide a description of the planned use of funds for salaries, wages, and/or fringe benefits. Certified Personnel listed here are also listed on the R-4. All Personnel listed here are listed on the R-5. Name of Personnel Position Amount Requested 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Total for Salaries, Wages, Fees and/or Fringes: $ 9/30/2024 14

  15. R-2A ESY PROJECTED BUDGET NARRATIVE SUMMER 2015 (SY2014-2015) Describe the budget items for each category. Documentation should be on file in the district to justify the necessity and reasonableness of each item. These pages may be reproduced as needed. Salaries/Fringes Use the section below to provide a description of the planned use of funds for salaries, wages, and/or fringe benefits. Certified Personnel listed here are also listed on the R-4. All Personnel listed here are listed on the R-5. Personnel are to be listed in alphabetical order. Name of Personnel Position Amount Requested 1. Sarah Johnson Teacher $3,046.63 1. Betty Lyle Teacher Assistant $1,001.53 1. John Smith Bus Driver $ 683.00 1. 1. 1. 1. 1. 1. 1. 1. 1. 1. $4,731.16 Total Salaries/w fringes 9/30/2024 15

  16. ESY PROJECTED BUDGET NARRATIVE SUMMER 2015 (SY2014-2015) Travel/Transportation Indicate travel costs for itinerant teachers Indicate travel costs for parents of students in ESY Indicate transportation cost of district buses DO NOT include transportation cost of students in private placement being transported by the facility Do include the transportation cost of students in private placement being transported by district buses Total amount matches the Cover Page (O-1) and the Projected Budget Summary Page (R-1) 9/30/2024 16

  17. R-2B ESY PROJECTED BUDGET NARRATIVE SUMMER 2015 (SY2014-2015) TRAVEL/TRANSPORTATION Use the section below to provide a detailed description of the planned use of funds for travel/transportation. Private Placement Costs should not be included. Private Placement Costs should be included on the R-3. Travel: # Students Served: Amount Requested: Transportation: Total for Travel: $ 9/30/2024 17

  18. R-2B ESY PROJECTED BUDGET NARRATIVE SUMMER 2015 (SY2014-2015) TRAVEL/TRANSPORTATION Use the section below to provide a detailed description of the planned use of funds for travel or transportation. Private Placement Cost should not be included. Private Placement Cost should be included on the R-3. Travel: # Students Served: Amount Requested: 1 $ 32.75 Example: Mileage for Sarah Johnson to provide homebound services to Steve Jackson. Example Transportation: 10 $ 3,794.00 2 346.00 Example: District School Bus Private Carrier Total for Travel: $ 4,172.75 9/30/2024 18

  19. ESY PROJECTED BUDGET NARRATIVE SUMMER 2015 (SY2014-2015) Contractual Services Indicate the cost of contractual service personnel to include travel costs List the names of Contractual Personnel Contractual Personnel listed here should also be listed on the ESY Roll (R-4) and the Service Provider Listing (R-5) Total amount matches the Cover Page (O-1) and Projected Budget Summary Page (R-1) 9/30/2024 19

  20. R-2C ESY PROJECTED BUDGET NARRATIVE SUMMER 2015 (SY2014-2015) CONTRACTUAL SERVICES Use the section below to provide a detailed description for the planned use of funds for contractual services to include travel cost. Personnel listed here are also listed on the R-4 and R-5. Contractual Personnel Service Provided Number of Hours Rate Number of Students Served Amount Requested 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. Total for Contractual Services: $ 9/30/2024 20

  21. R-2C ESY PROJECTED BUDGET NARRATIVE SUMMER 2015 (SY2014-2015) CONTRACTUAL SERVICES Use the section below to provide a detailed description for the planned use of funds for contractual services to include travel cost. Personnel listed are also listed on the R-4 and R-5. Contractual Personnel Service Provided Number of Hours Rate Number of Students Served Amount Requested 1. Mary Allen Speech 15 $25.00 5 $375.00 2. Central Hospital PT 16 $75.00 10 $1,200.00 3. Central Hospital OT 10 $75.00 5 $750.00 4. 5. 6. Example 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. Total for Contractual Services: $2,325.00 9/30/2024 21

  22. ESY PROJECTED BUDGET NARRATIVE SUMMER 2015 (SY2014-2015) Materials/Supplies/Commodities Provide an itemized listing of the items to be purchased Indicate the quantity, unit cost and extended price Equipment is not an allowable purchase Total matches the Cover Page (O-1) and the Projected Budget Summary Page (R-1) 9/30/2024 22

  23. ESY PROJECTED BUDGET NARRATIVE SUMMER 2015 (SY2014-2015) Materials/Supplies/Commodities Use the section below to provide a detailed description of the planned use of funds for the purchase of materials/supplies/commodities. Item Quantity 1. Unit Cost Amount Requested 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. Total for Materials/Supplies/Commodities: $ 9/30/2024 23

  24. ESY R-2D PROJECTED BUDGET NARRATIVE SUMMER 2015 (SY2014-2015) Materials/Supplies/Commodities Use the section below to provide a detailed description of the planned use of funds for the purchase of materials/supplies/commodities. Item Quantity Unit Cost Amount Requested $10.00 1. Potato chips 1 case $10.00 per case 2. Cookies 1 case $13.00 per case $13.00 3. Apples 1 case $40.00 per case $40.00 4. Disposable Diapers 5. Pens 4 boxes $23.99 per box $95.96 10 boxes $2.00 per box $20.00 6. Copier Paper 1 case $59.99 per case $59.99 7. 8. 9. Example 10. 11. 12. 13. 14. 15. 16. 17 18. Total for Materials/Supplies/Commodities: $ 238.95 9/30/2024 24

  25. ESY PROJECTED BUDGET NARRATIVE SUMMER 2015 (SY2014-2015) (Other) Provide a clear description of what other is Total matches the Cover Page (O-1) and the Projected Budget Summary Page (R-1) 9/30/2024 25

  26. ESY PROJECTED BUDGET NARRATIVE SUMMER 2015 (SY2014-2015) Other Use the section below to provide a description of the planned use of funds for other expenses incurred for Extended School Year. Other expenses should be clearly stated. Other: Amount Requested: Total for Other: $ 9/30/2024 26

  27. R-2E ESY PROJECTED BUDGET NARRATIVE SUMMER 2015 (SY2014-2015) Other Use the section below to provide a description of the planned use of funds for other expenses incurred for Extended School Year. Other expenses should be clearly stated. Other: Amount Requested: Example: Electricity for 3 classrooms at Central Elementaryfor 15 days $ 1,308.00 Example Total for Other: $ 1,308.00 9/30/2024 27

  28. PRIVATE PLACEMENT ESY Private Placement Initial Placement of Students School District Letter of Justification ESY page of the IEP with signatures Determination of Eligibility Department of Human Services Letter of Justification ESY page of the IEP with signatures Current Court Order Determination of Eligibility 9/30/2024 28

  29. PRIVATE PLACEMENT ESY Private Placement Students placed after program begins School District Letter of Justification ESY page of the IEP with signatures Determination of Eligibility Department of Human Services Letter of Justification ESY page of the IEP with signatures Current Court Order Determination of Eligibility 9/30/2024 29

  30. PRIVATE PLACEMENT ESY Private Placement (R-3) Daily rate used for calculation is $168.00 Transportation cost for private facilities is 82.00 unless you negotiated a lower rate Students listed here are also found on the ESY Roll (R-4) Students listed here must have an approved Educable Child application on file with a current eligibility ruling and a current IEP Transportation Cost for students in private placement is listed here and NOT on the Projected Budget Narrative for Travel/Transportation (R-2B) unless they are being transported by district buses 9/30/2024 30

  31. ESY PRIVATE PLACEMENT SUMMER 2015 (SY2014-2015) EDUCATIONAL Name of Facility Disability MSIS # IEP Beginning Date of Services Ending Date of Services # Days Served Daily Rate Amount MDE USE Alphabetical order: Approval Date Student Name 1 2 3 4 5 6 7 8 RESIDENTIAL Name of Facility Disability MSIS # IEP Beginning Date of Services Ending Date of Services # Days Served Daily Rate Amount MDE USE Alphabetical order: Approval Date Student Name 1 2 3 4 5 6 7 8 R-3 9/30/2024 31

  32. ESY PRIVATE PLACEMENT SUMMER 2015 (SY2014-2015) TRANSPORTATION Continued Student Name Date(s) of Facility Closure Date(s) of Therapy Participation Mode(s) of Transportation Cost(s) MDE USE **Only Amounts Included for Private Placement Total** 1. 2 3 4 5 6 7 8 MDE USE ONLY Transportation Total: Educational Total: Residential Total: Overall Total: Extended School Year Consultant Date Director, Division of Program Management Date 9/30/2024 32

  33. EXTENDED SCHOOL YEAR ROLL ESY Roll (R-4) All columns must be completed All students have a teacher s name and/or a service provider s name All personnel (teachers/service providers) can be found on the Service Provider Listing (R-5) All district personnel listed can be found on the Projected Budget Narrative (R-2A) All service providers can be found on the Projected Budget Narrative (R-2C) Justification for placement must match the IEP page 9/30/2024 33

  34. R-4 ESY STUDENT ROLL SUMMER 2015 (SY2014-2015) List all students served in ESY (including those students in private placement). Complete form R-3 for students served through private placement. JUSTIFI- CATION TRANSPOR- TATION AIDE RELATED SERVICES TOTAL DAYS TOTAL HRS DISABILITY NAME OF STUDENT MSIS ID NUMBER LOCATION OF SERVICES TEACHER PROVIDER SERVED SERVED AGE Y N C/S R/R E/S BUS P/C 1 2 3 4 5 TOTAL NUMBER OF STUDENTS SERVED 9/30/2024 34

  35. R-4 ESY STUDENT ROLL SUMMER 2015 (SY2014-2015) List all students served in ESY (including those students in private placement - R-3). TRANSPOR- TATION JUSTIFI- CATION TOTAL DAYS AIDE RELATED SERVICES TOTAL HRS DISABILITY SERVED SERVED MSIS ID NUMBER LOCATION OF SERVICES TEACHER PROVIDER NAME OF STUDENT AGE C/S R/R E/S Y N BUS P/C 1 Steve Jackson 0000001 9 MR 15 45 X Homebound Sarah Johnson OT Jayson Smith . PT Courtney Shaifer L/S Mary Allen 2 Aubree Hicks 7 15 45 X Central Elem Tammy Jones X OT Jayson Smith X 0000002 AU Example 3 4 5 TOTAL NUMBER OF STUDENTS SERVED 9/30/2024 35

  36. Individualized Education Program Page ESY Individualized Education Program Page Required committee members are listed along with their roles Annual goals or Short Term Instructional Objectives are listed to include goals for all related services being provided Date of meeting is listed Criterion used matches the criterion on the ESY Roll (R-4) 9/30/2024 36

  37. R-4A EXTENDED SCHOOL YEAR SERVICES Summer Session: Student s Name: Documentation of ESY Decision Critical Point of Instruction 1 Criterion used in determining eligibility: Regression-Recoupment Extenuating Circumstances MEETS criteria for ESY services DOES NOT MEET the criteria for ESY services (Documentation indicating how the decision was made must be included in the student s file.) Comments: Annual Goals or Benchmarks/Short-Term Instructional Objective(s) Critical Point of Instruction 2 T.A. * Method(s) Physical Location of Services Report of Progress (Codes or key phrases may be used) STIOs are only required for students who are Significantly Cognitively Disabled (SCD). (Per IDEA 04) EXPLANATION OF CODING SYSTEM Method(s) of Measurement Report of Progress 4. Progress made; Annual Goal or Objective not yet met 5. Annual Goal or Objective met 1. Written Observation 2. Written Performance 5. Time Sample 6. Demonstration/Performance 1. Not applicable during this grading period 2. No progress made 3. Little progress made 3. Oral Performance 4. Criterion-Referenced Test 7. Other (Specify) _____________ 6. Annual Goal or Objective maintained * * Committee Members Present _____________ Special Education Teacher Types of Services: # of # of days Amount of time per day Beginning/Ending Dates Names and positions of excused IEP Team Members (Documentation must be included in the student s file.): Name: Weeks Name: Name: _____________ Agency Representative _____________ Parent(s) Guardian Transportation Educational Services Name: Name: Student (if applicable) Other ____________ ____________ RelatedServices OT Name: Other Name: Other ____________ IEP meeting conducted via alternate means of technology: Video Conferencing Conference Call Other (Specify) The Report of Student Progress will be given to parents/guardians every _ __ weeks or_____ at the end of the student s ESY. W - 6 Date of Meeting: Date copy is given to the parent/guardian: _______________________________________________ * Check if goal/objective is a transition activity. (Student age 16 20) ** Does not require signatures; this section is utilized only to document individuals present at the meeting. 9/30/2024 37

  38. R-4A EXTENDED SCHOOL YEAR SERVICES Student s Name:Aubree Hicks Summer Session: 2015 Documentation of ESY Decision Criterion used in determining eligibility: Regression-Recoupment Critical Point of Instruction 1 Extenuating Circumstances MEETS criteria for ESY services Critical Point of Instruction 2 DOES NOT MEET the criteria for ESY services (Documentation indicating how the decision was made must be included in the student s file.) Comments: Annual Goals or Benchmarks/Short-Term Instructional Objective(s) T.A. * Method(s) Physical Location of Services Report of Progress (Codes or key phrases may be used) STIOs are only required for students who are Significantly Cognitively Disabled (SCD). (Per IDEA 04) Maintain skill of sight word vocabulary at present level of 23 of 24 words 2,3,6 Central Elem Complete all self-help non-feeding activities 6 Central hospital EXPLANATION OF CODING SYSTEM Method(s) of Measurement Report of Progress 1. Written Observation 5. Time Sample 1. Not applicable during this grading period 4. Progress made; Annual Goal or Objective not yet met 2. Written Performance 6. Demonstration/Performance 2. No progress made Example 5. Annual Goal or Objective met 3. Little progress made 3. Oral Performance 7. Other (Specify) _____________ 6. Annual Goal or Objective maintained 4. Criterion-Referenced Test * * Committee Members Present Alma Helps Types of Services: # of # of days Amount of time per day Beginning/Ending Dates Names and positions of excused IEP Team Members (Documentation must be included in the student s file.): Name: Special Education Teacher Weeks Name: Beth Can Regular Education Teacher Transportation Name: George Assist Agency Representative Educational Services 9 4 30 6/2/15-7/31/15 Name: Sally Doe Parent(s)/Guardian RelatedServices OT 3 2 1 6/2/15-6/19//15 Name: Student (if applicable) Name: Name: Name: _______________ _______________ _______________ Other Other Other IEP meeting conducted via alternate means of technology: Video Conferencing Conference Call Other (Specify) The Report of Student Progress will be given to parents/guardians every _4__ weeks or_____ at the end of the student s ESY. _______________________________________________ Date of Meeting: 3/29/15 Date copy is given to the parent/guardian: 3/29/15 W - 6 9/30/2024 38

  39. SERVICE PROVIDER LISTING Projected Service Provider Listing (R-5) All personnel are listed Personnel on the Projected Budget Narrative (R-2A) Personnel on the Projected Budget Narrative (R-2C) Personnel on the ESY Roll (R-4) Valid license numbers are listed and copies of licenses are submitted to include private school/facility personnel 9/30/2024 39

  40. ESY R-5 PROJECTED SERVICE PROVIDER LISTING SUMMER 2015 (SY2014-2015) (Personnel listed on R-2A, R-2C, and R-4 are also listed here) SERVICE PROVIDER NAME POSITION LICENSE # # STUDENTS TOTAL HRS 9/30/2024 40

  41. ESY R-5 PROJECTED SERVICE PROVIDER LISTING SUMMER 2015 (SY2014-2015) (Personnel listed on R-2A, R-2C, and R-4 are also listed here) SERVICE PROVIDER NAME POSITION LICENSE # # STUDENTS TOTAL HRS Mary Allen Speech Path. 0001234 6 25 JaysonSmith Occupational Therapist OT1235 1 8 Courtney Shaifer Physical Therapist PT 5312 6 10 Sarah Johnson Teacher 112568 10 25 Betty Lyle Teacher Assistant NA 1 8 Joan Smith Bus Driver NA 25 50 Example 9/30/2024 41

  42. REIMBURSEMENT Request for Reimbursement Completed and signed in blue ink (good practice to assure original copies) ESY Private Placement Reimbursement form is attached Reason(s) for Exiting ESY program are given Students names should be consistent Transportation cost and transportation rate are provided Educational costs are provided Total number of days are provided 9/30/2024 42

  43. R-6 REQUEST FOR REIMBURSEMENT EXTENDED SCHOOL YEAR SUMMER 2015 (SY2014-2015) DISTRICT NAME: ______________________________ DISTRICT CODE: _____________________ ACTUAL ESY EXPENDITURES Salaries $ Travel $ Contractual services $ Materials/Supplies/Commodities $ Private Placement $ Other $ Total $ B.STUDENT INFORMATION Disability Category Autism (AU) Deaf/Blind (D/B) Developmentally Delayed (DD) Emotional Disability (EmD) Hearing Impairment (HI) Intellectual Disability (ID) [EMS,TMR,S/P] Language/Speech Impairment (S/L) Number Served Disability Category Number Served Multiple Disabilities (MD) Orthopedic Impairment (OI) Other Health Impairment (OHI) Specific Learning Disability (SLD) Traumatic Brain Injury (TBI) Visually Impaired (VI) TOTAL As Superintendent of this district, I certify by my signature below and that to the best of my knowledge: This application for reimbursement represents the actual cost of operating ESY for the 2014 summer session. Sufficient documentation is available for audit inspection. The students with disabilities served met the ESY criteria established in accordance with the Mississippi Department of Education regulations and the educational services provided are specified in each student s Individualized Education Program. No expenditure(s) which would have been incurred if there had not been ESY is (are) included for reimbursement. Documentation to support expenditures is on file for audit inspection. 1. 2. 3. SUPERINTENDENT S SIGNATURE (Blue Ink) DATE Mail to: Mississippi Department of Education Office of Special Education Post Office Box 771 Jackson, MS 39205-0771 DUE DATE: September 30, 2015 9/30/2024 43

  44. R-6A ESY PRIVATE PLACEMENT REIMBURSEMENT FORM SUMMER 2015 (SY2014-2015) Alphabetical order: Student Name Last name, First name Beginning Date of ESY Services Ending Date of ESY Services Exit Reason Transportation Rate Transportation Cost Number of Days Served Educational Cost Total Amount MDE USE 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Total Page ______ of ______ Revised 12/2014 9/30/2024 44

  45. TOP ISSUES Teachers names do not match licenses Licenses expire before program begins or ends Licenses are not provided or License numbers are incorrect Students and teachers names are not consistent Names of service providers are not provided ESY Private Placement Sheet not included with Reimbursement Additional information requested not included Supervisor s license not included for OTAs/PTAs/BCaBA/RBT Teachers are not properly endorsed or certified 9/30/2024 45

  46. POINTS TO REMEMBER Request for Reimbursement is due September 30, 2015 Request for Reimbursement received on or before September 30th will be processed for 50% disbursement Final Request for Reimbursement is due December 15, 2015 The remaining 50% and Request for Reimbursement received after September 30th will be processed for payment in March and May of 2016 9/30/2024 46

  47. TIMELINES

  48. TIMELINES January 2015 3rd Period Educable Child Student Applications January 9 Determination of ESY may begin January 15 Personnel Snapshot Amendment January 30 February 2015 3rd Pay Period Educable Child Reimbursement February 3 Positive Behavior Specialist (PBS) Reimbursement February 12 Educational Interpreter (EI) Reimbursement February 12 9/30/2024 48

  49. TIMELINES March 2015 Extended School Year Applications posted March TBA 4th Period Educable Child Student Applications March 6 Final Draw for PBS and EI March 31 April 2015 4th Period Educable Child Reimbursement April 2 Determination of ESY ends April 15 9/30/2024 49

  50. TIMELINES April 2015 Justification for Maintenance of Effort April TBA Child Find Report April 30 Extended School Year Applications April 30 9/30/2024 50

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