Academic Integrity Incident Report



Academic Integrity Incident Report

To the Instructor: Please complete and submit this form to the Office of Academic Affairs within five (5) working days of your meeting with the student concerning the described incident.

Course: Click here to enter text.Section: Click here to enter text.Date of Occurrence: Click here to enter text.

Please check all that apply:

☐ Cheating on test ☐ Fabrication

☐ Plagiarism ☐ Other

☐ Collusion

Please describe the incident and findings:

Click here to enter text.

Please indicate the imposed sanctions (check one):

☐ Completion of an educational activity relating to the nature of the offense. Please describe the activity.

Click here to enter text.

☐ Assign a lower grade or score to the paper, project, assignment or examination involved in the act of misconduct. Please indicate lower grade or score that was assigned and to what it was assigned:

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☐ Require the student to repeat or resubmit the paper, project, assignment or examination involved in the act of misconduct.

☐ Assign a failing grade for the course.

☐ Withdraw the student from the course.

NOTE:

A sanction of assigning a failing grade in a course or withdrawing a student from a course cannot be carried out until the student indicates he/she does not wish to appeal the findings or sanctions, or has made an unsuccessful appeal. Therefore, until one of these two actions occurs, the student should be allowed to remain in the class.

Student acknowledgement of meeting with Instructor:

My instructor and I met to discuss the findings and sanctions indicated above. I have been advised of the

alleged act of academic misconduct and the information upon which it is based. I have been given an

opportunity to refute the allegation. My signature is an acknowledgement of this meeting. It is not an

indication of whether I agree with the conclusion of my instructor.

__________________________________________ ____________________________

Student Signature Date

To the Instructor: If meeting with the student did not occur, please check this box.

☐ I made a reasonable effort to schedule a meeting with this student. The student did not take necessary steps to arrange a meeting with me.

Student’s Name: Click here to enter text. Student’s ID: Click here to enter text.

☐ Mr. ☐ Ms. ☐ Dr. Click here to enter text.

(Check One) ___________________ _____________________ ________

Instructor’s Name Instructor’s Signature Date

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