Please complete the following as fully as possible. If you need assistance, contact the Level I investigator in your school.

 

Student's name and address: ______________________________________________________

                                              ______________________________________________________

Student's telephone no.:  _________________________________________________________

Student's school:   ______________________________________________________________

Name and place of employment of employee accused of abusing student:

______________________________________________________________________________

______________________________________________________________________________

Allegation is of ______ Physical abuse ______Sexual abuse*

Please describe what happened. Include the date, time and where the incident took place, if known. If physical abuse is alleged, also state the nature of the student's injury:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Were there any witnesses to the incident or are there students or persons who may have information about this incident?  ______ yes ______ no

If yes, please list by name, if known, or classification (for example "third grade class," "fourth period geometry class"):

______________________________________________________________________________

*Parents of children who are in pre-kindergarten through sixth grade and whose children are the alleged victims of or witnesses to sexual abuse have the right to see and hear any interviews of their children in this investigation. Please indicate "yes" if the parent/guardian wishes to exercise this right:

______ yes ______ no    Telephone Number _________________________

Has any professional person examined or treated the student as a result of the incident?

______ yes  ______ no ______ unknown

If yes, please provide the name and address of the professional(s) and the date(s) of examination or treatment, if known

______________________________________________________________________________

______________________________________________________________________________

Has anyone contacted law enforcement about this incident?  ______ yes ______ no

Please provide any additional information you have which would be helpful to the investigator. Attach additional pages if needed.

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Your name, address and telephone number:

______________________________________________________________________________

______________________________________________________________________________

Relationship to student: __________________________________________________________

Complainant Signature ___________________________________________________________

  Witness Signature _____________________________________________________________

Date _____________________  Witness Name (please print)____________________________

Witness Address _______________________________________________________________

Be advised that you have the right to contact the police or sheriff's office, the county attorney, a private attorney, or the State Board of Educational Examiners (if the accused is a licensed employee) for investigation of this incident. The filing of this report does not deny you that opportunity.

You will receive a copy of this report (if you are the named student's parent or guardian) and a copy of the Investigator's Report within fifteen calendar days of filing this report unless the investigation is turned over to law enforcement.

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Adopted: 2/9/09

Reviewed: 10/14/19

Revised: 4/8/13

Student's name: ________________________________________________________________

Student's age: _________________________  Student's grade:___________________________

Student's address: _______________________________________________________________

Student's school: _______________________________________________________________

Name of accused school employee: ____________________________ Building: ____________

Name and address of person filing report:

______________________________________________________________________________

Name and address of student's parent or guardian, if different from person filing report:

______________________________________________________________________________

Date report of abuse was filed: _____________________________________________________

Allegation is of  ________ Physical abuse  ________ Sexual abuse*

Describe the nature, extent and cause of the student's injury, if any and if known: (Attach additional pages if needed).

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Describe your investigation: Attach additional pages if needed. (Please do not use student witnesses' full names.

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

*Were parent(s) or guardian(s) advised of their right to see and hear any interview of their pre-kindergarten through

sixth grade children who are alleged victims of or a witness in a sexual abuse investigation?

 

________Yes ________ No       Was the right exercised?   ________Yes ________ No

 

Were audio tapes made of any interviews?  _______yes ________no

Were video tapes made of any interviews?  _______yes  _______no

Was any action taken to protect the student during/as a result of the investigation?

_______ yes ________ no

If yes, describe:

________student excused from school                 ________school employee placed on leave

________student assigned to different class         ________other (please specify)

 

Level I investigator's conclusions:

_____  The complaint is being dismissed for lack of jurisdiction.

_____  Physical abuse was alleged, but no allegation of injury was made.

_____  Physical abuse was alleged, but no evidence of physical injury exists and the nature

             of  the alleged incident makes it unlikely an injury, as defined in the rules, occurred.

_____  Sexual abuse was alleged, but the alleged actions of the school employee, even if

            true, would not meet the definition of sexual abuse in the rules.

            is not currently employed by this school district.

_____  Alleged incident did not occur on school grounds, on school time, at a

            school- sponsored activity, nor in a school-related context.

_____  The complaint has been investigated and concluded at Level I as unfounded.

_____  Complaint was withdrawn.

_____  Insufficient evidence exists that an incident of abuse, as defined in the rules, took place.

_____  The complaint has been investigated at Level I and is founded.

_____  The investigation is founded at Level I and is being turned over to Level II for

            further investigation.

_____  Investigation of the complaint was deferred at Level I and referred to law enforcement

            at this time.

_____  The investigation is concluded at Level I because the accused school employee

             has admitted the violation, has resigned, or has agreed to relinquish any teaching

             license held.

 

Current status of investigation:

 

_____  Closed. No further investigation is warranted.

_____  Closed and referred to school officials for further investigation as a personnel matter.

_____  Deferred to law enforcement officials.

_____  Turned over to Level II investigator.

 

Other comments: _______________________________________________________________

______________________________________________________________________________

I have given a copy of the report of abuse and of this investigative report to the employee named in the report, the employee's supervisor, and the student's parent or guardian and informed the person filing the report of the options of contacting law enforcement, private counsel, or the State Board of Educational Examiners, if the accused school employee holds an Iowa teacher's certificate or license.

Name of investigator (please print) _________________________________________________

Investigator's place of employment _________________________________________________

Signature of investigator _________________________________________________________

Date _________________________________________________________________________

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Adopted: 2/9/09

Reviewed: 10/14/19

Revised: 4/8/13

Pursuant to Chapter 102 of the School Rules of Iowa, abuse may fall into either of the two following categories.

1. Physical Abuse- The non-accidental physical injury to a student as a result of the actions of a District employee. Physical abuse may occur as the result of intentional infliction of injury or excessive, unnecessary, or unreasonable use of force in discipline.
2.  Sexual Abuse- Sexual offenses or misconduct as defined by Iowa Code Chapter 709. This definition also encompasses acts or omission of the District employee that allow, permit, or encourage the student to engage in prostitution as defined by Iowa law.

To constitute a violation of the Iowa Code, acts or omissions of the employee must have occurred on school grounds, on school time, on a school-sponsored activity, or in a school- related context. The student need not be a student in the school district, and can be from another school district.

It shall be the responsibility of the superintendent/designee to annually identify a designated investigator and an alternate investigator. The names and telephone numbers of these investigators shall be included in the employee handbooks.

An individual who has knowledge an employee has physically or sexually abused a student may immediately report it to the designated investigator or their alternate if the investigator is named in the report. The report shall be written, signed and witnessed by a person of majority age. The witness may be the Level I investigator. The report shall contain a completed response for each question on the Level I reporting form.

Upon request, the Level I investigator may assist the reporter in completing the report. An incomplete report will not be rejected unless the missing information would render the investigation futile or impossible.

To be investigable, the written report must include basic information showing that the victim of the alleged abuse is or was a student at the time of the incident, that the alleged act of the employee resulted in injury or otherwise meets the definition of abuse in these rules, and that the person responsible for the act is currently an employee. If the report is not investigable due to lack of jurisdiction, the investigator will dismiss the complaint and inform the reporter of other options available. Other options available to the reporter include contacting law enforcement authorities, private counsel, or the Board of Educational Examiners in the case of a licensed employee.

The investigator shall then make and provide a copy of the report to the person filing, the student's parent/guardian and the district employee named in the report. Within five (5) school days of receipt of the report, the investigator shall conduct an informal investigation to determine whether the allegations are true. In the course of this investigation, the investigator shall interview the alleged victim, the district employee named in the report, and any collateral sources who may have knowledge of the circumstances contained in the report. The investigator shall exercise prudent discretion to preserve the confidentiality interests of the individuals involved.

The investigator's role is not to determine the guilt or innocence of the involved party, but whether it is likely that an incident took place between the student and the district employee. If, in the investigator's opinion, the magnitude of the allegations suggests immediate and professional investigation is necessary, the investigator may waive informal investigation. In such cases, the investigator shall contact appropriate law enforcement officials, the child's parent/guardian, and the person filing the report, and shall document in writing the action taken.

Within fifteen (15) calendar days of receipt of the report, the investigator shall complete a written investigative report which shall include those items required by Chapter 102.9 of the Iowa Code. If the report is founded by a preponderance of the evidence, the investigator shall promptly notify law enforcement in case of sexual abuse allegations. The investigator may notify law enforcement authorities in serious cases of physical abuse. In addition, the investigator shall (1) file a copy of the report with the district employee's supervisor, (2) file a complaint with the Board of Educational Examiners in cases involving a licensed district employee, and (3) document all actions taken.

Any record created by an investigation shall be handled subject to formally adopted or bargained policies on the maintenance of personnel records.

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Approved:

Reviewed: 10/14/19

Revised: 4/8/13