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Academic Integrity and Plagiarism Notification Form
This form must be completed and routed to the chair/program director and dean of the department,
then sent to the office of the Vice President for Academics and Guided Career Pathways when a student
commits an act of academic dishonesty or plagiarism in violation of the Academic Integrity and
Plagiarism policy.
The signature of the instructor below confirms that the student identified in 2) has been disciplined for
academic dishonesty or plagiarism in the course identified in 4). The instructor also confirms that the
date and circumstances of the academic dishonesty or plagiarism are as described in item 5).
1. Instructor’s Name __________________________________________________
2. Student’s Name ____________________________________________________
3. Student ID Number __________________________________________________
4. Course Name and Section Number _____________________________________
5.
Date, Circumstances, and Nature of the Violation, (including consequences and date
student was notified): __________________________________________________
6. Decision: Charge No Charge
Instructor Signature __________________________________________________ Date ________________
Chair/Program Director Signature _______________________________________ Date ________________
Dean Signature ______________________________________________________ Date ________________
Revised 9/23/2019
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