2021 IAR Assessment
Form to Report Contaminated, Damaged, or Missing Materials
1. Follow the instruc ons in the Test Coordinator Manual if test materials become contaminated (Sec on 4.2.3), damaged (Sec on 4.2.3), or missing (Sec on
2. Then report the incident using this form to describe the circumstances.
3. Submit the form via fax or mail.
Contact Name __________________________________________________________ Contact Phone and Ext
Person’s Role
Contact Email __________________________________________________________
School Name __________________________________________________________ School RCDTS Code __________________________________________________
District Name
Complete this form and submit the completed form to Pearson via one of the following
Fax 319-341-5261
ISBE Program Team
Mail Stop PB044
2510 North Dodge St., Iowa City, IA 52245
Document Type/Subject/Grade Quan ty
Security Barcode
or Range of
Barcode Numbers
Descrip on of Circumstances
Grade 8 ELA Test Booklet
1 123456789-0
Student had a nosebleed on the booklet and it has now been
destroyed according to District protocol.