Academic Integrity Reporting Form

Your Information

Your full name:

Your position/title:

Your phone number:

Your email address:

Email address must be of a valid format.

Date of incident(Required):

This field is required.

Time of incident:

Location of incident(Required):

This field is required.

Specific Course:

Learn more

Course Name, Course Number

Involved Parties

Student Name

Select Gender

Select Role

Student ID

Questions

Please complete the following questions:

What, if any, academic consequences have issued as a result of this alleged academic violation? Please note: An instructor retains initial authority over any academic grade issued within a course.(Required) This field is required.

Besides the academic penalty listed above, is there any action you would like Student Conduct to pursue against the student? If so, please select from the options below.(Required) This field is required.

Has the instructor met with student to discuss this alleged academic misconduct violation?(Required)

Yes No

This field is required.

If the instructor was unable to meet with the student to discuss the matter in person, did the instructor notify the student of the alleged violation, and if so how?(Required) This field is required.

Please provide the date you met with, or plan to meet with the student. This field is required.

Does the student agree or accept responsibility for the allegation of committing academic misconduct?(Required)

Yes No Unknown (submitting report before student meeting occurs)

This field is required.

Does the student agree with or accept the recommended academic resolution of this matter, as proposed by the instructor?(Required)

Yes No

This field is required.

Please choose the what charge the student is being responsible for.(Required) This field is required.

Please provide a detailed description of the incident/concern using specific concise, objective language (who, what, when, where, why, and how).(Required) This field is required.

Supporting Documentation

Please include a copy of your Conference Report, as well as any other Supporting Documentation available to you. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Email me a copy of this report

Your Information

Involved Parties

Questions

Supporting Documentation

Submission