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Academic Misconduct/Plagiarism Incident Report

Background Information

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Your full name:

Your position/title:

Your phone number:

Your email address:

Email address must be of a valid format.

Your physical address:

Nature of this report(Required):

This field is required.

Date of incident(Required):

This field is required.

Time of incident:

Your School or College(Required):

This field is required.

Course (e.g. POLS 111.001):

Involved Parties

Please list the individuals involved (excluding yourself), including as many of the listed fields as you can provide.

Involved party 1

Name or Organization

ID Number

Email address

Description/Narrative

Your Department This field is required.

Reason(s) for Report(Required)

Plagiarism Other acts of Academic Misconduct (cheating, falsifying data, failure to follow clinical practice standards, etc.)

You must make at least one selection.

Do you believe this incident was...(Required)

Intentional Not Intentional

You must make at least one selection.

Course Title(Required) This field is required.

Please provide a detailed description of the alleged misconduct using concise, objective language (Who, what, where, when, why, and how). Describe any evidence in support of the allegation. If witnesses are available, please provide their names and contact information.(Required) This field is required.

If you are the faculty member of record for this course, policy 3C2 and 1I6 allow you to apply a limited range of sanctions in response to the incident. Please select the sanction you applied to the student from the list below.(Required)

Discussion with Student and/or Opportunity to Correct Problem

Failing grade on individual course assignment

Failing grade for the course

Removal from field experience

You must make at least one selection.

University policy requires that faculty who impose sanctions for academic misconduct/plagiarism communicate in writing with the student. In addition to completing this incident report, have you communicated in writing with the student?(Required)

Yes No

You must make at least one selection.

Supporting Documentation

Photos, video, email, and other supporting documents may be attached below. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Submission

Email me a copy of this report