Student-Athlete Sexual and Interpersonal Violence Attestation Form
Concordia University Wisconsin (University) and the National Collegiate Athletic Association (NCAA) are committed to sexual
violence prevention. Sexual discrimination, sexual harassment and sexual and interpersonal violence violate human decency and
the Association’s core values. (NCAA Board of Governors Policy on Campus Sexual Assault)
Requirements
1. Who:
2. When:
All prospective (first year), incoming (transfer)
and returning student-athletes.
Every year of intercollegiate athletics participation
(includes tryout, practice and competition).
3. What:
Attest (disclose) if the prospective/incoming/returning student athlete has been disciplined through a Title IX or sexual
misconduct proceeding or criminally convicted, regardless of the degree, and whether the result of a plea or court
determination, of either of the following:
 Sexual Violence: A term used to include both forcible and nonforcible sex offenses, ranging from sexual battery, sexual
assault to rape.
 Interpersonal Violence: Violence that is predominantly caused due to the relationship between the victim and the
perpetrator, including dating and domestic violence.
 Other Acts of Violence: Crimes including murder, manslaughter, aggravated assault, or any assault that employs the
use of a deadly weapon or causes serious bodily injury.
Attestation (Please initial next to appropriate selections below)
___
I attest that I HAVE NOT been found responsible for violating a high school, college or university policy or been subject to
discipline through a Title IX or sexual misconduct proceeding or criminally convicted for sexual violence, interpersonal
violence or any other act of violence as described above, AND that I did not leave any prior institution with conduct charges
PENDING for such acts.
OR
___
I attest that I HAVE been found responsible for violating a high school, college or university policy; or been subject to
discipline through a Title IX or sexual misconduct proceeding; or criminally convicted for sexual violence, interpersonal
violence or any other act of violence as described above OR HAVE PENDING charges through a Title IX or sexual misconduct
proceeding.
Was the Title IX or sexual misconduct proceeding complete or pending at the time of your transfer to the University?
___ Complete ___ Pending Institution Name: ________________________________ Date: __________
Where you criminally convicted?
State: ____________________ County: _____________________ City: _______________ Date: _______
By signing below, I attest that, to the best of my knowledge and belief, that all information attested to on this form is accurate and
complete, and that providing purposefully false information on this form could result in disciplinary action, up to and including
expulsion and penalties, including loss of my eligibility to participate in athletics, or revoking a students’ admission as
determined by the University and/or the NCAA.
Women’s Sport: _________________________________________ Men’s Sport: ________________________________________
Athlete Status:
___ First Year
___ Transfer
___ Returning
Student Name: _________________________________ Signature: ________________________________ Date: _____________
Signature of Parent/Guardian (if student athlete is under 18): ____________________________________ Date: _____________
Please return this document to: athletics.compliance@cuw.edu