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: _________________ _______ physical _______ sexual*
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 or as a result of the investigation? _____ yes _____ no
If yes, describe:
_____ student excused from school _____school employee placed on administrative or other 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.
_____Alleged victim was not a student at the time of the incident.
_____Alleged school employee 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
