Special Education Association of Peoria County



SPECIAL EDUCATION ASSOCIATION OF PEORIA COUNTY

4812 W Pfeiffer Rd., Bartonville, IL. 61607

Ph: 309-697-0880 Fax: 309-697-0884

ESY DATA FORM

School Year: 2021

| | |

|CURRENT YEAR INFORMATION |ESY SPEECH ONLY AND RELATED SERVICES ONLY |

| | |

| | |

| |MINUTES |

| | |

| | |

| |Service Provider |

| |Start |

| |Date |

| |Stop |

| |Date |

| | |

| | |

| |SEAPCO |

| |LEA |

| | |

| | |

| | |

| |13 |

| | |

| |Occupational Therapy |

| |      |

| |      |

| |      |

| |      |

| | |

| |19 |

| | |

| |Physical Therapy |

| |      |

| |      |

| |      |

| |      |

| | |

| |23 |

| | |

| |Speech/Language |

| |      |

| |      |

| |      |

| |      |

| | |

| |25 |

| | |

| |Transportation (Special) |

| |      |

| |      |

| |      |

| |      |

| | |

| | |

| |Other |

| |      |

| |      |

| |      |

| |      |

| | |

| | |

|Legal Name: Last |First |Middle | |

|      |      |      | |

|Birth Date:       |Sex:       |Disability Code:       | |

|Resident District:       |Serving District:       | |

|Current Grade:       |Current Program:       |Current Teacher:       | |

|Annual Review Date:       |Eligibility Determination Date:       | |

|ESY AND RELATED SERVICES |

| |

|MINUTES |

| |

| |

|Service Provider |

| |

| |

|SEAPCO |

| |

|LEA |

|Start |

|Date |

|Stop |

|Date |

| |

|02 |

|Aide: Classroom |

|      |

|      |

|      |

|      |

| |

|03 |

|Aide: Individual |

| |

|      |

|      |

|      |

| |

|08 |

|Consultant |

|      |

|      |

|      |

|      |

| |

|13 |

|Occupational Therapy |

|      |

|      |

|      |

|      |

| |

|18 |

|Psychological Services |

|      |

|      |

|      |

|      |

| |

|19 |

|Physical Therapy |

|      |

|      |

|      |

|      |

| |

|23 |

|Speech/Language |

|      |

|      |

|      |

|      |

| |

|24 |

|Social Work Services |

|      |

|      |

|      |

|      |

| |

|25 |

|Transportation (Special) |

| |

|      |

|      |

|      |

| |

|28 |

|Behavior Intervention Plan |

|      |

|      |

|      |

|      |

| |

| |

|Other |

|      |

|      |

|      |

|      |

| |

| |

|ESY PROGRAM OPTIONS/MIN |

|Program |

|Mins/Week |

|Start |

|Date |

|Stop |

|Date |

| |

|Public Day: SEAPCO ESY |

|Location: PVMS/3780 |

|720 |

|6/14/2021 |

|7/15/2021 |

| |

|Senior ESY/3600-SEAPCO Offices |

|1440 |

|6/28/2021 |

|7/13/2021 |

| |

| |

|Public Day: SEAPCO Academy/3780 |

|720 |

|6/14/2021 |

|7/15/2021 |

| |

|HISRA |

|      |

|      |

|      |

| |

| |

|Tutoring |

|      |

|      |

|      |

| |

| |

|Remote: |

|      |

|      |

|      |

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Administrator’s Signature:       Date:   /  /    

-----------------------

RETURN To: Rosemary Skinner @ SEAPCO

Email: rskinner@

Fax: 309-697-0884

Ph: 309-697-0880 Ext.201

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