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.
