COMPETENT PRIVATE INSTRUCTION REPORT
IOWA CODE SECTION 299.4
________ - ________ SCHOOL YEAR

 

Required information:  See instructions before completing.

The following information is required in accordance with Iowa Code section 299.4.  Parent/Guardian must submit this report in duplicate to the school district of resident.  This report is required if the student is between the ages of 6 and 16 by September 15 and does not attend an Iowa public or accredited nonpublic school or is not enrolled in a home school assistance program operated by an Iowa public or accredited nonpublic school.  Return this form to the school district secretary by the first day of school or within 14 calendar days of removing the student from a public or accredited nonpublic school or 14 calendar days from moving into the school district. 

(If you are enrolled in a home school assistance program please notify the district if you plan to dual enroll.)

Child and Family Information:

1. Name and birth date of child under competent private instruction.

 

_                                                                                                                                                                          
              (Name)                                                                                                      (Birth Date)

 

2. Name and address of person filing report.

 

_                                                                                             ___Parent   ___Guardian   ___Legal Custodian
              Name)

 

_                                                                                                                                                                          
              (Address, City, Zip)                                                                    Phone Number (optional)

             

3. Immunization Information:  If filing Form A for the 1^st time, attach immunization information.

Instruction Program Information:

 

4. Outline the course of study either in the space or on a separate page(s).  Attach lesson plans on separate page(s).

Subject                                             Text and Publisher or Author                     Time Spent

_                                                                                                                                                           

 

_                                                                                                                                                           

 

_                                                                                                                                                           

 

_                                                                                                                                                           

 

_                                                                                                                                                           

 

_                                                                                                                                                           

 

5. List number of days of instruction under competent private instruction __________
   (must be at least 148 days, Iowa code section 199A.1).

 

6. If an Iowa licensed teacher will provide or supervise the parent, guardian or legal custodian in providing the instruction, give the teacher’s name and folder number.

 

_                                                                                                                                                          
              (Name)                                                                          (Teacher folder number)

_                                                                                                                                                          
              (Address)                                                                      (Teacher signature-optional)

                                                                                                                                                                          
                              (City/State/Zip)                                                            (Phone number-optional)

 

7. If an Iowa licensed teacher is not providing instruction or supervising the parent, guardian, or legal custodian providing instruction the child must take an annual assessment unless the child is enrolled in an accredited correspondence school.  To date the Iowa Department of Education is not aware of any accredited schools (Please see the acceptable annual assessments on page 14.  The school district will notify parents by October 1^st of testing dates.)

 

8. If the child is currently identified as a child requiring special education prior approval must be sought from the special education director at the Area Education Agency if this is the first year that the child will be receiving Competent Private Instruction in Iowa.  Iowa Code section 299A.9

 

The Following Information is Optional, however
If your child plans to participate in any academic or extracurricular activities at your local school district or to have your child’s annual assessment provided at no charge,
complete the following:

 

9. Do you desire dual enrollment in the public school for the child under competent private instruction:

 

Yes __________ No __________   (If no, skip to #10.)

 

1. Dual enrollment is desired for:

 

Academic _____   Extra-curricular activities _____   Testing _____   (Check all that apply)

 

2. Grade Level for the ________ - ________ school year __________

 

3. Subjects or Activities you wish your child to dual enroll in:

 

1^st Semester                                                                   2^nd Semester

_                                                                                                                                                           

                                                                                                                                                             

                                                                                                                                                             

 

10. Do you desire to enroll in a Home School Assistance Program if offered?  Yes _____   No _____

Deadline for dual enrollment and/or Home School Assistance Program is September 15, within 14 calendar days after moving to the district, or within 14 calendar days after removing the child from school.

Note:  Due to the restrictions as to the number of students who may be served in a Home School Assistance Program, Timely filed requests may be denied if the program already serves 20 families or 40 students.  281-IAC 31.3(3)