The University of Tampa
Reporting Form for Academic Integrity Violations and Academic Misconduct
___________
(student’s initials)
___________
(student’s initials)
The student may not withdraw from the class once an AI violation is recorded.
This course may not be repeated
under the grade forgiven
ess policy
This form will stay in the Office of the Associate Provost
Date
email or
STATEMENT OF STUDENT (To be completed by student)
____
_____
__
.
Student Signature _________________________________________________
Date
Faculty Member Signature __________________________________________
Date
Academic Witness Signature ________________________________________
Date
Academic Witness Print Name _______________________________________
Associate Provost Signature _______________________________________
Date
__________
SIGNATURES
RECORD OF INCIDENT (To be completed by instructor)
Student’s Name __________________________________________ Student ID# ______________________
Faculty Member’s Name ____________________________ Dept. _____ Course Code _________Section
Date of incident: _____________ Student Classification:_____
Description of incident (continue on the back of this form, if necessary):
Sanction imposed for this violation
ACADEMIC INTEGRITY RECORD (To be completed by instructor)
Contact the Office of the Associate Provost for prior violations, and please check the appropriate box:
Student has no prior violation(s)
Verified by email
or phone
T
he student has prior violations (list number in the box):
on
___________
(enter date)
I understand the AI violation and have discussed the incident and the evidence with the instructor. I
understand that this document will be maintained in the Office of the Associate Provost. I elect the following:
_______ I accept the decision of the instructor and agree to abide by all imposed sanctions.
_______ I wish to have my case referred to the Office of the Associate Provost for adjudication. I understand I must submit
written supporting documents or arguments to the Office of the Associate Provost (AssociateProvost@ut.edu)
Verification Date ____________________ Associate Provost Representative
accompanied by the syllabus and the supporting evidence (i.e. exam, essay etc.)***
__________
__________
__________
Recorded number of previous academic integrity violation(s). Date received
***Please note that the Office of the Associate Provost cannot accept forms unless they are completely filled out, and
VERFICATION OF RECORD OF CONDUCT (To be completed by the Office of the Associate Provost)
Term the violation occurred________
click to sign
signature
click to edit
![]()
click to sign
signature
click to edit
![]()
click to sign
signature
click to edit
![]()
click to sign
signature
click to edit
![]()
