| If yes to any of the following, please provide further documentation. | Yes | No |
|---|
| 1. Has the student ever been found responsible in a Title IX or related disciplinary proceeding for sexual, interpersonal or other acts of violence? | | |
| 2. Has the student ever been criminally convicted for sexual, interpersonal or other acts of violence? | | |
| 3. Did the student have a Title IX or related disciplinary proceeding pending for sexual, interpersonal or other acts of violence when the student left the institution? | | |
INSTITUTION OFFICIAL'S SIGNATURE: ___
DATE: ___