Academic Misconduct Reporting Form

Background Information

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Your full name:

Your position/title:

Your phone number:

Your email:

Email address must be of a valid format.

Nature of this report(Required):

This field is required.

Date of incident(Required):

This field is required.

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Use the date of the quiz/exam or the date the assignment was submitted

Course Subject(Required):

This field is required.

Specific Course Number:

Involved Parties

List all faculty, staff, and students involved in this incident. You should enter as much information as possible for all alleged students and witnesses. You do not need to include yourself in this section. If you do not have a piece of information please leave that field blank.

Student Name

Role of Student

ID Number

Email Address

Information about Incident

Please fill in all fields below with as much detail as possible. Please be aware that the student could request a copy of the report and/or it could be given to the student as part of their "panel packet" if they request a Student Honor Council review.

Provide a detailed narrative of the incident. In your narrative consider the following questions: How did you become aware of the incident? Did you directly witness the violation? Did anyone else witness the violation (please include all witness information above)? What percentage of the assignment/exam/quiz was the student's own work? This section should also include your opinion on the severity of the violation.(Required) This field is required.

For which of the following charges did you determine the student was responsible? (Ex. Cheating, Plagiarism)(Required) This field is required.

Identify the academic remedy you assigned (select as many that are applicable).(Required)

Opportunity to re-do the assignment Reduced grade on the assignment Failing grade on the assignment Zero grade on the assignment Failing grade in the course Other

You must make at least one selection.

Provide a summary of your meeting with the student. Consider the following questions: How did the alleged student react in your meeting? Did the student take responsibility?(Required) This field is required.

Would you like to be contacted with the outcome of the University's review of the incident? If you select no, but at a later date would like information regarding this incident please contact CHECS.(Required) This field is required.

Please select your preferred method of communication. (Choose all that apply)(Required) This field is required.

Are there any other specific concerns or questions you want the CHECS Staff to discuss with you? This field is required.

Supporting Documentation

Please attach any supporting documentation you may have regarding this incident. Supporting documentation could include, but is not limited to, a letter indicating that academic misconduct has occurred, copies of assignments with cheating or plagiarism indicated, copies of sources that have been plagiarized, and the course syllabus/assignment instructions. If you prefer to deliver hard copies of documentation please do so to the Center for Honor Enrichment and Community Standards on the Third Floor of the David Student Union Building. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Email me a copy of this report

Background Information

Involved Parties

Information about Incident

Supporting Documentation

Submission