South CarolinaStateUniversity

Teacher Education Program

Academic and Professional Character Screening

Name: ______UWID: ______

Major: ______Date: ______

Answer each question by circling Yes or No. If, you answer Yesto any of the questions, provide a full explanation on a back of this form or on a separate sheet of paper.

NOTE: Criminal offenses are felonies, misdemeanors and summary offenses. (Some examples of these crimes are driving under the influence of intoxicating beverages, drugs, writing fraudulent checks, disturbing the peace; and leaving the scene of an accident)

1.Have you ever had a professional certificate, license, credential, or other document issued for professional practice, denied, suspended, revoked or requested to surrender your credentials? Yes No

2.Have you ever been dismissed, asked to resign or retire; discharged from a professional position or military services for immorality, incompetence, and willful neglect of duty or misconduct; or presenting false information toward obtaining a position or privilege? Yes No

3.Have you ever been arrested, convicted, or entered a plea of no contest; withheld in a criminal offense to include driving under the influence; other minor traffic violation; or currently have criminal charges pending against you? Yes No

4.Have you ever been sanctioned by South CarolinaStateUniversity for any of the following acts of prohibited or academic misconduct? Yes No

5. Circle all that are appropriate.

  1. Copying on examinationsYesNo
  2. Plagiarizing major portions of written assignmentsYesNo
  3. Using prohibited materials during an examination YesNo
  4. Acquiring or distributing an examination from an unauthorized

source, prior to an examination Yes No

  1. Presenting the work of another person as my ownYesNo
  2. Using purchased term papers or other materials for a gradeYes No
  3. Fabricating data by inventing or deliberately altering materials Yes No

I affirm and declare that all information given on this form is true and complete to the best of my knowledge. Any misrepresentation of facts, omissions, and additions may result in sanctions to include expulsion from my program of academic preparation.

Student Name ______

Signature Date