Dispositions Transgression Report Form

Please complete the information requested and submit to the Department Chairperson or his/her designee within five (5) business days of meeting with the candidate. Include any documentation such as emails between you and the candidate, copies of assessments, time logs, reports from SBTEs or school personnel etc.

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Today's Date Today's Date / MM / DD YYYY
Date of Pre-Disposition Meeting With Student (in person, phone, or virtual) Date of Pre-Disposition Meeting With Student (in person, phone, or virtual) / MM / DD YYYY

The person submitting the disposition referral form must meet with the teacher candidate to discuss the alleged transgression, explain that a disposition report may be filed with the department, and share the disposition policy and policy guidelines.
Teacher Candidate Name Teacher Candidate Name First Last
Banner ID
Must be 9 digits. Currently Entered: 3 digits.
Department

Department ELID KSSPE Health Other Other
Program
Faculty/Staff Submitting Form Faculty/Staff Submitting Form First Last
Title
Email of Faculty/Staff Submitting Form
Will more than 1 Faculty/Staff Member be contributing to the form?
Faculty/Staff Submitting Form Faculty/Staff Submitting Form First Last
Title
Faculty/Staff Submitting Form Faculty/Staff Submitting Form First Last
Title
Faculty/Staff Submitting Form Faculty/Staff Submitting Form First Last
Title
Faculty/Staff Submitting Form Faculty/Staff Submitting Form First Last
Title
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Dispositions Transgression Report Form

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