Reporting Form for Academic Dishonesty to Academic Affairs Integrity File
F
or all cases of violations to the Academic Integrity Policy, please complete and return this form
to the Dean (who will then forward it to the Vice President for Academic Affairs in the Office of
Academic Affairs).
Please Print Clearly or Type (computer version will automatically adjust to content)
Reporting Date
Date of Incident
Student's Name
Student's ID#
Faculty's Name
Department
Faculty Phone
Faculty Email
Course Name
number/section
Detailed
Description of
Incident
Date of Conference with Student
F
aculty Action/Recommended Action: Use ATfor action taken or RAfor recommended action
"F" in course
Lower grade on the assignment/paper
"F" or zero on assignment
Written reprimand from Dean placed on
student’s record
Re-do assignment/paper
Tutoring
Lower final course grade
Other, please specify:
______
______________________________ _______________________
Signature of person reporting incident Date
Student intends to file a grievance on this action: Yes No
______
_____________________________ ________________________
Student Signature* Date
____________________________________ ________________________
Dean Signature Date
Dean must forward this report and all pertinent documentation to the Academic Affairs Integrity File
in the Office of Academic Affairs. Academic Affairs will forward a copy of this form to the Athletic
Compliance Officer if student is a student athlete.
*Student signature acknowledges receipt of a copy of this report and that student has been apprised of his/her
rights stated in Section 5 of the Code of Student Conduct and particularly that the faculty member is required to
file a record with the Office of Academic Affairs whenever a student is confronted and/or disciplined for cheating
(Reporting Form for Academic Dishonesty
). If student refuses to sign reporting form person reporting incident
should duly note such in space provided for student signature. Documentation of student receipt of copy of
form via email may also be attached in lieu of student signature. The Office of Academic Affairs will maintain
these records and any student confronted and/or disciplined for multiple offenses (more than one) of
academic dishonesty will be brought before the Academic Affairs Integrity Committee (AAIC) for further review
and/or sanctions.
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