ABUSE OF STUDENTS BY SCHOOL DISTRICT EMPLOYEES
Report of Level I Investigation
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: ________________ ________________ ________________
Allegation is of ________________ Physical abuse ________________ Sexual abuse*
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 the parent(s) or guardian(s) advised of their right to see and hear any interview of their pre-kindergarten through twelfth grade children who are alleged victims 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 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 allegations 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 the 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 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 and Iowa teacher's certificate or license.
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Name of investigator (please print) Investigator's place of employment
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Signature of investigator Date
