Policy Title: Private Instruction
Code No.: 622 E1
COMPETENT PRIVATE INSTRUCTION REPORT
Directions: Complete one form in duplicate 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 (school start date) or within 14 calendar days of removing the child from 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).
A. MANDATORY INFORMATION. (This information is required by Iowa Code §299.4).
1. Child and Family Information: Name and birthdate of child under competent private instruction.
(Child’s Name) (Birth date)
2. Name and address of person filing report. Circle One:
_____________________________________ Parent Guardian Legal custodian
(City, State, Zip Code) (Phone Number) (optional)
3. Immunization Evidence: If filing for the 1st time, attach immunization information. (Proof of immunization is required of all children receiving CPI, including those enrolled in a HSAP)
4. Instructional Program Information: Outline the course of study either in the space or
on a separate page(s). Attach lesson plans on separate page(s).
Text, Publisher and Author
5. List number of days of instruction under competent private instruction ____________
(Must be at least 148 days per academic year, Iowa Code § 299A.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.
Teacher folder #:
Teacher signature (optional)
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. The school district will notify parents by October 1st of testing dates.)
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.) However, if your child needs to access special education programs or services, or if your child plans to participate in any academic or extracurricular activities at your local school district, or if you wish to have your child’s annual assessment provided at no charge, complete the following:
8. Does the child require special education services? ______Yes ______No
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 before the child may receive Competent Private Instruction in Iowa. Iowa Code § 299A.9.
9. Do you desire dual enrollment in the public school for the child under competent private instruction? Yes ___ No ___ (If no, skip to #10.)
Private Instruction Code No. 622 E1 Pg. 2
A. Dual enrollment is desired for: (Check all that apply)
Academic ____ Extra-curricular activities ____ Testing ____ Special Education ______
B. Grade Level for the 20____-20____ school year _________
C. Subjects or Activities you wish your child to dual enroll in:
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 15th, 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).
Date of Approval/Revision
Private Instruction Code No. 622 E1 Pg. 3