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 |