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: ___________________________
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Name and address of student's parent or guardian, if different from person filing report:
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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).
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Describe your investigation: Attach additional pages if needed. (Please do not use student witnesses' full names.)
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*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Complaint was withdrawn.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________________________________________________
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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
Approved 09/11/95
Reviewed 10/18/21
Revised 11/11/13
