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Social Work Department
St. Cloud State University
Disclosure Form
By signing this document I, the student, understand that I am
certifying to the truthfulness of the answers to the following
questions. Such questions are asked on employment and licensure
applications because they may have an impact on your ability
to practice social work.
While in the Social Work Department I have a continuing obligation
to provide correct and up-to-date information to the following
questions. Failure to provide up-to-date information or the
provision of willful misinformation or omission of information
will effect my continuation in the program.
An affirmative response to any of the questions below will require
discussion in the admissions interview but does not mean that
you will be automatically disqualified from the major.
Please answer the following questions. If you answer “yes”
to any question, please explain below.
1. Have you been convicted of a misdemeanor in the last 5 years?
Yes No
2. Have you been convicted of a felony in the last 5 years?
Yes No
3. Are you currently charged with a felony?
Yes No
4. Are you currently charged with a misdemeanor?
Yes No
5. Have you ever been expelled from a post secondary institution
or subject to disciplinary action at a post secondary institution?
Yes No
6. Have you ever had a grade changed due to academic dishonesty
or been asked to leave a class due to academic dishonesty?
Yes No
7. Is there anything in your personal life that could interfere
with you becoming an effective social worker?
Yes No
Explanation:
Date_______________ Student Signature_________________________________
Date_______________ Signature of Faculty Interviewer_____________________
4/2004
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