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Campus Safety Questionnaire

Personal Information

All personal information is required.

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Your full name:

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First, Middle, Last

Date of Birth:

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mm/dd/yyyy

Your phone number:

Your email address:

Email address must be of a valid format.

Your physical address:

Time of incident:

Specific location:

Involved party 1

Full Name

Select Gender

ID Number (no dash; if you do not have an ID, please leave this blank)

DOB (YYYY-MM-DD)

Phone number

Email address

General Information

Term Applying For:(Required)

Summer 2024 Fall 2024 Spring 2025

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Preliminary Questions Have you ever been convicted of a crime(s), received a deferred sentence(s), or have any pending charges?(Required)

Yes No

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Are you currently on probation?(Required)

Yes No

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Are you currently on parole?(Required)

Yes No

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Have you ever been subjected to court-ordered confinement for threatening or causing physical or emotional injury to persons or property?(Required)

Yes No

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Have you ever been disciplined, suspended from, placed on probation, or have any pending student conduct or Title IX cases at any educational institution for behavioral disciplinary reasons?(Required)

Yes No

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Have you ever been required to register as a sexual or violent offender?(Required)

Yes No

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If you have been convicted of a crime, Number each crime, and complete A-G for each crime committed. (A) Crime/Disciplinary Action, (B) Date of Crime Occurrence, (C) Statue(s) or other regulations violated, (D) Court in which conviction(s) deferred sentence took place (Specific state, county or federal district), (E) Date of conviction, (F) Circumstances surrounding crime(s) for which you were convicted, (G) Sentence(s) or sanctions imposed, If you have not been convicted of a crime, type "n/a" in this box.(Required) This field is required.

If you've been incarcerated, Number each instance of incarceration, and complete A-C for each instance. (A) Institution(s) where sentence(s) was or is being served (prison, jail, pre-release, etc) (B) Start and end date of sentence, and Amount of time actually served (C) Circumstance surrounding release from incarceration (for each conviction); (parole? pardon? furlough? served time in full?) If you are subject to parole or probation, state the terms, when completed, or if not completed, date of expected completion. If you have not been incarcerated, type "n/a" in this box.(Required) This field is required.

If you have pending charges, Number each pending charge, and please describe the situation and the anticipated completion (adjudication) timeline. If you do not have pending felony charges, type "n/a" in this box.(Required) This field is required.

If you have been disciplined for non-academic reasons at an educational institution, Number each conduct, and complete A-G for each crime committed. (A) Institution at which disciplinary action was imposed (B) Date of action (C) Nature of conduct for which you were disciplined (D) Regulation or policy violated (E) Circumstances surrounding violation for which you were disciplined (F) Discipline imposed (suspension? probation? others) (G) Period of time for which suspension or probation was imposed and date completed, if applicable (H) If suspended, have you applied for readmission? Were you readmitted? Were there any conditions imposed upon your readmission? If you have not been disciplined for non-academic reasons at an educational institution, type "n/a" in this box.(Required) This field is required.

If you have been required to register as a sexual or violent offender, Provide the jurisdiction and the details of the registration (e.g., level of offender, link to registration website, date of registration etc.) If you have not been required to register as a sexual or violent offender, type "n/a" in this box.(Required) This field is required.

Treatment, Rehabilitation & Corrective Actions Are you currently under or have your ever been under court ordered treatment for alcohol, drugs, anger management or sexual offences?(Required)

Yes No

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Please give the following information on required AND/OR voluntary treatment: (A) Whether treatment was voluntary or court-ordered. (B) Nature of rehabilitation therapy (name, location) and amount completed (for example, Chemical Dependency Treatment, MRT, Parenting, Anger Management, etc). Include dates of treatment beginning and end, if complete. (C) Amount of rehabilitation therapy completed (support group(s), counseling, etc) If you have not been required to complete treatment AND have not completed voluntary treatment, type "n/a" in this box.(Required) This field is required.

Additional Information List contact probation officer, conduct officer, attorney, police officer, Officer of the Court, or other educational administrator who can provide additional information regarding the disciplinary action(Required) This field is required.

I give permission for the MSU Campus Safety Questionnaire Committee to contact the above mentioned probation officer, conduct officer, attorney, police officer, or Officer of the Court to discuss information listed on this Safety Questionnaire.(Required)

Yes No

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Final Essay Your goals at MSU and how your life has changed to enable you to succeed in a campus environment.(Required) This field is required.

Supporting Documentation

You are required to attach court documentation or documentation from university discipline to this application. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Personal Information

General Information

Supporting Documentation

Submission