Academic Integrity Misconduct Incident Report Form

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:

Incident Type(Required):

This field is required.

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Please select

Date of Incident(Required):

This field is required.

Time of Incident:

Relevant Course:

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Please include the course number in which this incident occurred. (Ex: COMM 4020)

Involved Parties

Please list the individuals involved (excluding yourself), providing as many of the listed fields as you can provide. ID Number = DU Student ID #.

Involved party 1

Name

Select Role

ID Number

DOB (YYYY-MM-DD)

Incident Information

Please provide a detailed description of the incident/concern using specific, concise, and objective language

Incident Report Writing Tips:

* Complete the report thoroughly and accurately, including all pertinent information about the incident and persons involved (time, place, date, names, and addresses). The report should answer who, what, when, where, and how.

* To avoid confusion about which individual you are referring to, use third person and identify individuals with their last name and title, when appropriate.

* Be concise and to the point, while still being thorough and complete.

* Do not write from your emotion - leave editorial out. Use objective instead of subjective language. Include only factual information about the student's actions or behaviors, not your feelings about those actions/behaviors.

* Do not speculate - you are reporting facts, not possible assumptions.

* Complete the report as soon as possible after learning about the situation and speaking with the involved student(s).

* Make sure to proofread the text of your Incident Report before submitting.

Incident Description: A summary of your Incident Description will be sent to the student.(Required) This field is required.

Question 1: Student Rights and Responsibilities encourages you to gain the student's perspective about the situation prior to submitting this form. Please attach any documentation associated with the student's perspective to this form. Have you addressed this concern with the student directly?(Required)

Yes, in a meeting (phone, virtual, in-person) Yes, through email Not yet, but scheduled No, student has declined to meet No, student has not responded to outreach No, other reason

This field is required.

Question 1a: Please describe the nature of the interaction, as applicable. This field is required.

Question 1b: If you have not yet met with the student, would you like a member of the SRR team to attend the meeting as support?

Yes No Unsure, would like to discuss with SRR

This field is required.

Question 2: Are you reporting this incident for informational purposes only? Informational reports are NOT considered a part of a student’s reportable SRR record and the involved student(s) will not receive any University Outcomes. Please note that informational reports are appropriate when a report is for a minor assignment for a course, is not a severe violation of policy, does not result in a higher-level Academic Action, and is the first Academic Integrity Misconduct Incident Report that involves a specific student. SRR will contact you and discuss next steps if these criteria are not met.(Required)

Yes No

This field is required.

Question 3: In DU’s Academic Integrity Misconduct Process, SRR does not determine a student’s Responsibility. After the student has provided their perspective, the faculty member determines if a student is or is not Responsible for violating DU’s Academic Integrity Policy. Have you determined that the student is Responsible for violating DU’s Academic Integrity Policy?(Required)

Yes, and the student accepted Responsibility Yes, and the student did not accept Responsibility This report is for informational purposes only Unsure, a meeting with the student has not yet occurred Unsure, discussing with my dean/department head Other

This field is required.

Question 3a: Please explain. This field is required.

Question 4: SRR has no authority to impose Academic Actions. As the faculty member, all grading decisions are yours. For guidance on typical Academic Actions, please review this reference sheet. What Academic Action(s) have you imposed as a result of this incident? (Please select all that apply.)(Required)

None Re-Do Assignment or Test Grade Deduction on Assignment or Test Zero or Failure (F) on Assignment or Test Grade Deduction in Course Zero or Failure (F) in Course Recommended Removal from Academic Unit to Chair, Dean, or Other Decision Maker in Unit or Department No Action Yet – Reviewing with Chair, Dean, or Other Decision Maker in Unit or Department Other

You must make at least one selection.

Question 4a: If other, please explain. This field is required.

Question 5: SRR has the authority to assign University Actions or Outcomes. SRR aims to be consistent, equitable, educational, and restorative when assigning these outcomes. Based on your experience with this student and/or situation, what recommendation(s) do you have for the Educational Outcomes assigned in this situation? (Please select all that apply.)(Required)

None, this report is informational Academic Integrity Reflection Paper Writing Center Consultation Math Center Referral Academic Advising Consultation or Academic Coaching Career & Professional Development Consultation Referral to Another Subject-Specific Campus Resource Other

You must make at least one selection.

Question 5a: If you selected Referral to Another Subject-Specific Campus Resource or Other, please explain and/or provide contact information for that resource. If appropriate, SRR will work to provide this opportunity to the student(s). This field is required.

Question 6: Please share any additional information that SRR should be aware of regarding this situation. This field is required.

Question 7: Please list the name(s) and email address(es) for anyone in your department/unit who should be included in case follow-up and/or copied on correspondence from SRR to the involved student(s). This field is required.

Question 7a: How would you like the above listed individual(s) to be involved? (Please select all that apply.)

They will be handling ALL case follow-up and I do not wish to be involved beyond answering clarifying questions specific to this report. They should be copied on all follow-up communication from SRR. They should be copied on the official correspondence sent to the student(s) associated with this incident. Other

You must make at least one selection.

Question 7b: If other, please explain. This field is required.

Supporting Documentation

Please upload all supporting documentation for this case (as applicable) including course syllabus, student work, correspondences with student(s), TurnitIn Reports, etc.

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