1. Read your case and evidence from the Open Learning Faculty Member.
2. Please answer the following question by checking either “Yes” or “No.”
3. Enter the date.
4. Enter your digital signature by clicking the appropriate signature box and follow the instructions in Adobe Reader or
Adobe Acrobat. Make sure that you do not make any changes to the document after you sign it.
5. Save this form to your computer and email it back to your Open Learning Faculty Member within seven (7) days of
If this form is not returned within
seven (7) days
of receipt, the Open Learning Faculty Member will proceed.
When you receive this form back from the student please proceed with #1, below.
If you do not receive the form from the student within seven (7) days, please proceed with #2, below.
1. Check to ensure that the student has entered their digital signature.
2. Enter your digital signature by clicking the appropriate signature box below and following the instructions in Adobe
Reader or Adobe Acrobat. Make sure that you do not make any changes to the document after you sign it.
3. Save this form to your computer.
4. Forward this form to email@example.com with a copy of the evidence such as assignment or work in question (PDF is
preferred, but not necessary) within seven (7) days.
Step Two - To be completed by Student within seven (7) days of receipt
Step Three - To be completed by Open Learning Faculty Member
I have reviewed the information in
the form as well as the evidence
Digital Signature of Student
Digital Signature of Open Learning Faculty Member
Further comments may be added on Page 5
of this document to explain your case.
A copy of this documentation will be sent to
the student by the Recording Secretary for
the Academic Integrity Committee.
I, ________________________________________ (STUDENT NAME) have been made aware of Academic
Integrity Policy ED 5-0, as well as my alleged violation of this policy.
I am aware that, as per Policy ED 5-0, I will be given an opportunity to make a written submission to the
Academic Integrity Committee. If I feel there has been an error in the Academic Integrity process, I have the
right to an appeal as per policies ED 4-0 (Student Academic Appeals) and ED5-0 (Student Academic Integrity).
I am aware that I may contact the Office of Student Affairs for assistance. It has been explained to me that a record of this
violation will be placed in the Academic Integrity database and held confidentially in the Office of Student Affairs and
that the only individuals who will have knowledge of my involvement in this occurrence will be the people signing this form,
the Chairperson of the Academic Integrity Committee and the Director of Student Affairs.
Email: firstname.lastname@example.org, or Phone: 250-828-5023
all official correspondence from the committee will be sent to students at their MyTRU email address.
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