604.1E1 - Competent Private Instruction Report

604.1E1 - Competent Private Instruction Report

Directions:       Complete one form in duplicate (carbon or photo-static copy) for each child for whom the compulsory education law is being met in other than regular enrollment in a public school or accredited non-public school.  NO REPORT IS NECESSARY if the child is not of compulsory attendance age (6-16 with birth date prior to September 15) or if the child is enrolled in a home school assistance program in a public or a state accredited nonpublic school.  Reporter should retain a copy of this report for personal records.

Return to the school district secretary by ______________________(school start date) or within 14 calendar days of removing the child from public or accredited nonpublic school.

 

A.        MANDATORY INFORMATION.  (This information is required by Iowa Code §299.4).

            1.         Name and birth date of child under private instruction.
                        (Use one form for each child).

                       

                        Child’s name_____________________________________Birth date  _________

 

            2.         Name and address of person filing report:

 

                        Name  ____________________________________________________________

 

                        Address___________________________________________________________                        

 Circle one:  Parent     Guardian     Custodian

 

                        City/State/Zip______________________________________________________

 

            3.         School year and resident school district:

                        (e.g. 2000- 2001)_________  Resident School District  _____________________

 

            4.         Number of days of instruction for the school year.___________(minimum of 148)

 

 

5.         Name and address of person providing instruction to the child, and relationship to the child.

 

                        Instructor______________________________Relationship to child  _________
                                                                                     (parent, guardian, custodian, or  licensed teacher)

                        Address_________________________________________________________

 

                        City/State/Zip  ___________________________________________________

 

            6.         Will instruction be provided or supervised by a person with a valid Iowa teacher’s license/certificate appropriate for the age and grade level of the child?

                                                _______Yes                ______No

 

                        If yes, print folder number of teacher:  ___________________folder number

                       

Name of Iowa licensed teacher:  ____________________________________

 

Note:  If properly licensed teacher provides or supervises instruction in accordance with 281 I.A.C. 31 of the rules of the Iowa Department of Education, no annual assessment is required.  Otherwise a baseline test the first year and annual assessments thereafter are required of all students over 7 years of age who are in private instruction.

            7.         List subject covered in instruction and approximate amount of time spent on each.  Use extra sheet if necessary. 

                        Circle one:  daily     weekly     monthly     quarterly    by semesters     annually

                        ________________________________________________________________

                        ________________________________________________________________

                        ________________________________________________________________

                        ________________________________________________________________

 

            8.         Identify texts used including title and author or publisher and grade level series. 

                        Use extra sheet if necessary.

                       ________________________________________________________________

                        ________________________________________________________________

                        ________________________________________________________________

 

9.         If the child is being placed under private instruction for the first time, or for all children for whom no evidence was provided in a previous school year, attach evidence
                        of the child’s immunizations as required by Iowa law.  Evidence includes a doctor’s statement, a copy of a public health record, or the name and address of last school
                        attended, or any other formal evidence of the dates and typed of inoculations.

                                    Attached________________Previously provided to:  _______________
                                          
(tell where, when, and to whom evidence was provided.)

                        Please attach lesson plans for the period of instruction for the academic school year as required by Iowa Code §§ 299.4.

 

B.        OPTIONAL INFORMATION  (Note:  Although not required by law for reporting purposes under Iowa Code §299.4, failure to respond may result in loss of some                            privileges or available options to parents, guardians or custodians.)

            10.       a.  Indicate whether or not you desire dual enrollment in the public school for the child under competent private instruction.

                                    _____Yes                                ______No

                        b.  Indicate whether dual enrollment is desired for

                                    Academics                  Extra curricular activities                    Both   

            11.       If the child is dual enrolled in the public school, please specify in which grade level you wish to include the child for the purposes of academic or extracurricular
                        activities.

Grade Level  ________

            12.       If the child is dual enrolled, of which activities do you wish to be notified (e.g. field trips, vocal or instrumental music opportunities, physical education class, drama, art
                        music, science lab, driver’s ed, track, volleyball, academic decathlon, mock trial, etc.)?

            13.       Is the child currently identified as a child requiring special education:

                                    _____Yes                    ______No

                        (If “yes,”  approval of the AEA Director of Special Education is required before the child can be placed under competent private instruction.)

                        ___________________________________________________
                        Signature of AEA Special Education Director or designee

            14.       If the answer to question 6 is no, please indicate the desired method of assessment:

                        ______Standardized testing               ______Portfolio evaluation

                        A baseline test is required the first year of home schooling regardless of which type of assessment is chosen if the child is under the annual assessment requirement.

            15.       Please indicate which test you desire to use for Baseline (B) or Annual Assessment (AA) purposes:

                                    ______B         ______AA

                                    California Achievement Test (CAT)

                                    Metropolitan Achievement Test (MAT)

                                    Comprehensive Tests of Basic Skills (CTBS)

                                    Stanford Achievement

                                    Iowa Tests of Basic Skills (ITBS) grade K-9 only

                                    Stanford Achievement Test (abbreviated)

                                    Iowa Tests of Educational Development (ITED) grades 9-12 only.

                        Grade level of test desired

                        ______Fall Norms      ______Winter Norms    ______Spring Norms

            16.       If your answer to question 14 is portfolio evaluation, please provide name of portfolio evaluator, if known, and folder number.

                                    Portfolio Evaluator  ____________________Folder Number  __________

                                    Please provide me with a list of trained portfolio evaluators.

            17.       Do you wish to have the school district or Area Education Agency notify you of the dates it will be conducting testing sessions, so your child can take a baseline  or
                        annual assessment test at the same time?

                                    ______Yes                  _____No

 

            18.       If you answered yes to questions 10 or 17, please provide the name, address, and telephone number of the person who desires to be notified.

 

                                    Name  __________________________  Address  ___________________

 

                                    Telephone  ___________________City/State/Zip  ___________________

 

It is the responsibility of the test administrator to submit the results of the child’s baseline test, and if standardized testing form or assessment is chosen, the annual standardized test results to the parent, guardian, or custodian of the child; to the district of residence; and to the Iowa Department of Education annually by June 30.  If portfolio assessment is chosen, the responsibility of the portfolio evaluator is to provide a narrative report assessing the child’s progress to the child’s parent, guardian, or legal custodian; to the district of residence; and to the Iowa Department of Education by June 30 annually.  All reports to the Department should be sent to :  Iowa Department of Education, Attention:  Student Assessment Results, Grimes State Office Building, Des Moines, IA  50319-0146.

 

dawn.gibson.cm… Sun, 07/11/2021 - 15:06