DISCLOSURE QUESTIONNAIRE
Name ______________________________________SSN__________________________Date ___________________
Attach additional pages as necessary to fully respond to questions below.
Dept.
Initial
1. Have you ever had a teaching license?
Has teac
hing licensure been denied/revoked/suspended in any state in the United States for
reasons other than insufficient credits or courses? If “Yes,” please describe situation:
Is revocation or suspension pending? If “Yes,” please describe situation:
Yes No
Yes No
Yes No
_______
_______
_______
2. Have you ever been suspended, expelled, placed on probation (other than for collegiate
skills) or otherwise disciplined by any col
lege or university or from any program of a
colle
ge or university, either for academic or othe
r reasons? If “Yes,” please describe
situat
ion:
Yes No
_______
3. Have you ever been terminated for cause from an employment situation? If “Yes,” please
describ
e:
Yes No
_______
4. Have you ever been suspended, discharged or otherwise disciplined for conduct relating
to the health, welfare, safety, or education of any pupil?
Yes No
_______
5. Have you ever been suspended, discharged, or otherwise disciplined for conduct relating
to the breach of commonly accepted moral or ethical standards?
Yes No
_______
6. Have you ever been investigated for any conduct listed in Questions 4 and 5 above?
Yes No
_______
7. Have you ever been under investigation, involved in, convicted of, pled guilty to, pled no
contest to, or forfeited bail for
any criminal conduct under law or ordinance, or is any such
situation pending, excluding minor traffic violations? If “Yes,” please describe situation:
(Note: T he existence of a c riminal r ecord or d enial, r evocation or s uspension of a l icense d oes n ot
constitute an automatic b ar t o admission and is considered only as t hey s ubstantially r elate t o t he
duties of the program and eventual license.)
Yes No
_______
8. Have you ever been reported to the state school superintendent for any conduct listed in
the above questions?
Yes No
_______
9. Are you able to perform the duties and responsibilities of a f ield experience or practicum,
teacher candidacy, or internship with or without reasonable accommodation?
If “Yes, with accommodat
ion” is checked, please describe with what reasonable conditions or
circumstances you are able t o c arry out the duties and r esponsibilities of the pos ition w hich
you seek:
(Note: Wisconsin Lutheran College makes reasonable accommodations.)
Yes w/ accomm
Yes w/o accomm
No
_______
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A CRI MINAL HI STORY BA CKGROUND CH ECK b ased o n i nformation o n t his form w as p erformed through t he WISCONSIN
DEPARTMENT OF JUSTICE – CRIME INVESTIGATION BUREAU (http://wi-recordcheck.org/).
DATE: _________________ Order Number: _____________ RESULTS: ___________________________________
CHECK PERFORMED BY: _____________________________ - Wisconsin Lutheran College - School of Education
8800 West Bluemound Road
Milwaukee, Wisconsin 53226
________________________________________
WLC School of Education Director
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