Faculty Referral/Summary Adjudication Form
*Pl
ease print this form and submit the Office of Student Conduct following the meeting with the
student. An acknowledgement from the student’s Foxmail account may also be used as an electronic
signature.
Name of Student:
Name of Faculty Member:
____ We have reached the above agreement concerning the allegations and sanctions imposed.
The student and faculty have come to an agreement regarding the incident and the
matter is resolved.
____ We have reached the above agreement concerning the allegations but the student does not
agree with the grade sanction imposed. The student may appeal the grade sanction using
the Grades Appeal Policy.
____ We have not reached an agreement regarding an alleged incident of academic integrity. As
a result, a formal hearing with the Academic Integrity Panel is requested.
_____ I am referring this case to the Office of Student Conduct to coordinate the hearing process
due to actions or allegations being egregious.
__________________________________ ___________________
Student’s Signature
Date
__________________________________ ___________________
Faculty Signature
Date
Other Comments or Notes:
