Los Angeles Pierce College
Los Angeles Pierce CollegeACADEMIC DISHONESTY REPORT FORMStudent’s Name_________________________________________________________________ID#___________________________ Last First MiddleCourse Information:_____________________________________________________ ________________________________ Title Section NumberName of Instructor and/or Examiner:_______________________________________________________________________ (Please print)Date of Incident:_____________________________________________________________________________________________Description of Incident:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ (Please attach additional information and/or documentation if necessary) Action(s) Taken: (check all that apply)Assigned failing grade to the examination or assignment in which the alleged cheating or plagiarism occurred.Dismissed student from class/activity for___________class session(s) (Student may be suspended for up to 2 meetings) Form Submitted By:___________________________________________________________________________ Signature of Instructor or ExaminerThis is to certify that:· I have received and read the above report.. I understand this form is being referred to the Dean of Student Engagement for possible further action. Student Rights:· I understand that I may consult with the Vice President of Student Services regarding appeal rights. . My signature does not admit guilt.Student’s signature:_________________________________________Date:___________________ (Recommended but not required)Copies to: Dean of Student Engagement Instructor StudentRev. 5/05 ................
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