ACADEMIC INTEGRITY
COMPLAINT FORM
Office of Student Advocacy and Accountability
Mims Hall, Room 207
Ofc: 985-549-2213| FAX: 985-549-5103
osaa@southeastern.edu
This form is to be used for Academic Integrity Violations only. For details regarding the process, please refer to
the Academic Integrity Policy in the University Catalogue. After all required academic actions have been taken,
please make copies for the appropriate Department Head and Dean of your college area and forward a copy to
the Office of Student Advocacy and Accountability.
STEP 1 - COMPLAINT INFORMATION
Instructor’s Name_______________________________________________ Phone # __________________________
Em
ail ________________________Department __________________________ Course _______________________
Student’s Name____________________________________________________ W #__________________________
Provide a brief description of the violation (Please include the date the incident occurred and attach all supporting
documents; i.e. email communications, written assignments, etc.): (Use reverse side if necessary)
Instructor’s Signature________________________________________________ Date__________________________
STEP 2 - INSTRUCTOR’S ACTIONS
____Notified student in writing of the violation and the right
to appeal. (This can be via an email). Date: ___________
__Met with student. Date_______________________
__Student agreed that incident occurred.
__Student DID NOT agree that incident occurred.
__Student did not respond to the notice of charge by
(date) ___________________
Academic action taken:
□ Assigned lower grade to test or assignment.
□ Assigned F to test or assignment.
□ Other __________________________________
□ Assigned lower grade in course.
□ Assigned F in course.
__Informed student of academic action taken. Date _______________________
__Recommend disciplinary action beyond academic action. ___ Yes ___ No
__Provided written report of action taken and a copy of this from to Dept. Head and Dean of course. Date ______
STEP 3 - DEPARTMENT HEAD’S ACTIONS
Dept. Head of course received appeal from student: □ No □Yes, Date appeal received: __________, Approved____ Denied____
If appeal was approved, what was the appeal decision? ________________________________________________________________
__Informed student of appeal decision. Date informed _____________; ___Informed instructor of appeal decision. Date _________
__Informed Dean of appeal decision. Date informed__________; Recommend disciplinary action beyond academic action __Yes __ No
__Provided a copy of this form to Dean of course. Date ____________________________
Dept. Head’s name ____________________________________________________ Date _______________
STEP 4 - DEAN’S ACTIONS
Dean of course received appeal from student: ____ No ____Yes: Date appeal received: ______________ Approved_____ Denied____
If appeal was approved, what was the appeal decision?_______________________________________________________________
__Informed student of appeal decision. Date ______________ ; __ Informed Dept. Head of course of appeal decision. Date_________
__Informed instructor of appeal decision. Date _____________Student’s major__________________________________________
__Referred case to OSAA for disciplinary action beyond academic action. _______ Repeated acts, ______ egregious act.
__Provided copy of report and this form to Department Head and Dean of the student’s major, and to OS.
Dean’s Name_______________________________________________________________________ Date________________
STEP 5 – FOR OSAA USE
Date complaint received by OSAA and uploaded to Maxient ________________ OSAA Staff:___________________________
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