EDUCATIONAL PROGRAM
604.1E1 - COMPETENT PRIVATE INSTRUCTION REPORT
Directions: Complete one form in duplicate (carbon or photostatic copy) for each child for whom the compulsory education law is being met in other than regular enrollment in a public school or accredited nonpublic 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 school district secretary by the first day of school 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 birthdate
2. Name and address of person filing report:
Name
circle one:
address parent guardian custodian
city/state/zip
3. School year and resident school district:
(e.g., 199 -9 ) resident school district
4. Number of days of instruction for the school year (min. 148)
5. Name and address of person providing instruction to the child, and relationship to child.
Name
address
city/state/zip
Circle one: parent, guardian, custodian, licensed teacher
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 no.
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 subjects 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 types 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.)
/Date __________
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 Test
_ __ Iowa Tests of Basic Skills (ITBS) grades K-9 only
_ __ Stanford Achievement Test (Abbrev.)
_ __ 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 number 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 of 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, Attn: Student Assessment Results, Grimes State Office Bldg., Des Moines, IA 50319-0146.
Reviewed: 12/20/21