Chattanooga State Community College
Academic Integrity Violation Report
To be completed by faculty / staff member:
Submitted by: ______________________________ Office phone: ____________________
Date of Incident: ____________________ Course: ____________________
Name of student: ______________________________ Student ID#: ____________________
Description of the incident: ____________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Possible penalties/sanctions: ____________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Description of the action taken by the faculty/staff member: ________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
To be completed by faculty/staff member – check and initial where appropriate:
I, the faculty/staff member, have attached the supporting documentation that is required.
Yes: _____ No: _____ (please initial) __________
I, the faculty/staff member, have notified the appropriate department chairperson of the action.
Yes: _____ No: _____ (please initial) __________
I, the faculty/staff member, have notified the student and scheduled a conference with him/her.
Yes: _____ No: _____ (please initial) __________
I, the faculty/staff member, have presented the student with a copy of the Academic Integrity
Violation Report and supporting documentation.
Yes: _____ No: _____ (please initial) __________
I, the faculty/staff member, have discussed the contents of the Academic Integrity Violation
Report with the student and have notified him/her of possible sanctions.
Yes: _____ No: _____ (please initial) __________
I, the faculty/staff member, have given the student a chance to respond to this claim in writing.
Print Form
Yes: _____ No: _____ (please initial) __________
I, the faculty/staff member, have notified the student of his/her right to due process.
Yes: _____ No: _____ (please initial) __________
I, the faculty/staff member, have provided the student with a copy of the official procedures
he/she is to follow to request a hearing.
Yes: _____ No: _____ (please initial) __________
To be completed by the student:
I, the student, accept responsibility for the actions specified on this report.
Yes: _____ No: _____ (please initial) __________
If no, a written response must be attached.
I, the student, have been informed of the possible penalties/sanctions.
Yes: _____ No: _____ (please initial) __________
I, the student, have been notified of my right to due process.
Yes: _____ No: _____ (please initial) __________
I, the student, have been given the opportunity to respond to this claim in writing.
Yes: _____ No: _____ (please initial) __________
I, the student, have been provided with the procedures in writing to request a formal hearing.
Yes: _____ No: _____ (please initial) __________
I, the student, elect to request a formal hearing and agree to follow the procedures provided by
the faculty/staff member.
Yes: _____ No: _____ (please initial) __________
I, the student, waive my rights to a formal hearing.
Yes: _____ No: _____ (please initial) __________
This report will be filed as a first offense report but will not be used as a formal judicial charge
unless further incidents are reported or additional judicial review indicates that necessity. In the
event that the faculty member or the judicial officer requests judicial review, student rights to due
process and judicial hearing information will be explained in a judicial conference.
Student’s Signature: ______________________________ Date: ____________________
Faculty’s Signature: ______________________________ Date: ____________________
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