LaGuardia Community College
Academic Integrity Complaint Form
This form is used for cases involving bribery, cheating, academic fraud, misconduct on internships,
plagiarism and other forms of academic dishonesty, which fall under the Disciplinary Process of the Policy
on Academic Integrity. Please see brochure on Policy on Academic Integrity for a full explanation.
STUDENT’S NAME: (Please Print)
EMPL ID:
COURSE & SECTION:
DESCRIPTION OF INCIDENT: (Please Include date of incident and attach documentation if available.)
ACADEMIC SANCTION:
INSTRUCTOR’S NAME: (Please Print)
INSTRUCTOR’S SIGNATURE
DATE:
STUDENT TO FILL IN THIS PORTION:
I have read the complaint above and (check the appropriate statement)
I do not challenge the accusation and accept the sanction.
I challenge the accusation and wish for the matter to be referred to the Chief Academic Integrity Officer for further review.
I do not wish to make any statement at this time and; I am aware that the sanction will be upheld without further review
for appeal, after fifteen days of receipt of this notice.
STUDENT’S SIGNATURE DATE
FACULTY & CHAIRPERSON TO FILL IN THIS PORTION:
Student failed to appear for scheduled conference or could not be contacted.
The matter above has been resolved. Please keep on file.
The matter above must be referred to the Chief Academic Integrity Officer for further review.
CHAIRPERSON’S SIGNATURE DATE
Please return completed form to Room C-317
Gold Student
Pink Instructor
Yellow Chairperson
White Adjudicator
CHIEF ACADEMIC INTEGRITY OFFICER DATE
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