Faculty Form for Suspected Incidents of Academic Dishonesty
It is necessary to complete this form to report any instances of suspected academic dishonesty. Please review
the CUNY Policy on Academic Integrity. Print out a copy of this report for your records. Forward the Faculty
Form for Suspected Incidents of Academic Dishonesty and original paper suspected of academic dishonesty,
along with the copies of all available supporting documents, to:
Office of the Dean of Student Affairs
Room A-216, 718-368-5563
INSTRUCTOR INFORMATION:
Instructor Name:
Department: _________________________________________________________________
Telephone Number: __________________________ E-mail: ____________________________________________
Course: ______________ Section: ____________ Semester: ___________________________________
STUDENT INFORMATION:
Student Name: __________________________________________ Student ID: ___________________
INCIDENT INFORMATION:
Date of Incident:
Type of Incident:
If other, please describe: ___________________________________________
Explanation
of Incident: ____________________________________________________________________________
Did the student admit to the charge of cheating, plagiarism or other act of academic dishonesty?
☐ Yes ☐ No
Explanation: ______________________________________________________________________________
Have you resolved the matter informally?
☐ Yes ☐ No
If yes, please state how?
☐ A failing grade on the exam/paper ☐ A failing final grade
☐ Other (please explain) ______________________________________________________________
If no, do you advocate further action by the college and possible referral to the Faculty- Student Disciplinary
Committee?
☐ Yes ☐ No
Signature of Faculty Member: __________________________________ Date:
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signature
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