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The University of Texas at Tyler (University of Texas at Tyler)

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The University of Texas at Tyler
Ben and Maytee Fisch College of Pharmacy
Office of Student Affairs
Professionalism Alert (Non-Academic Alert)
General Information: This form may be used to report professionalism concerns, including suspected Honor Code violations. The form is typically completed
by the faculty/staff member observing the behavior or the administrator reporting the behavior.
General Instructions: Please save this form to your computer and then complete the form. When finished, attach the completed form to an email. Filling out
the form solely on the website will result in submission of a blank form.
Student’s Full Name:
Student ID #:
Preferred Phone Number:
Academic Year:
☐P1 ☐P2 ☐P3 ☐P4
Patriot Email:
@patriots.uttyler.edu
☐Other:
Faculty’s Full Name:
Faculty Email:
Course Number and Title:
Faculty Phone:
Please indicate the category for the reported professionalism concern:
1,2,3,4
Professionalism Alert – General:
☐
Dress Code
☐
☐
Excessive Absenteeism and/or Tardiness
☐
☐
Other: ____________________________________________________________________________________________________________________
Professionalism Alert – Suspected Honor Code Violation:
☐
Respect
☐
☐
Non-Academic Honesty/Integrity
☐
Please describe the incident(s) that prompted this alert and documentation, if applicable.
Continued on page 2
1
Suspected Honor Code Violations and Professionalism Alerts should be reported using this form.
2
Suspected Scholastic Honesty Violations should be reported using the UT Tyler Scholastic Dishonesty Report Form.
3
Requests for a Grade Appeal should be completed using the UT Tyler Grade Appeal Form.
4
Petitions to the Professional and Academic Standards Committee (PASC) should be submitted using the PASC Petition Form.
Page 2: Faculty Recommended Sanction (Select all that apply)
Under guidelines set forth by the policies and procedures of The University of Texas at Tyler, appropriate sanctions for non‐academic
ethics violations (e.g., College of Pharmacy Honor Code; MOPP Section 8‐803‐ 805) include informal and formal warnings, suspension or
dismissal from the College and/or University, and referral to appropriate outside legal (e.g., courts), regulatory (e.g., state boards of
pharmacy) or professional authorities (e.g., counseling, Behavioral Intervention Team).
Informal Sanctions: A copy of this report and accompanying documents are not placed in the student’s file. However, if an additional
report(s) is/are filed, this report may be submitted along with new information to the FCOP Professional and Academic Standards
Committee. The FCOP Office of Academic Affairs retains a copy of this form until the student has completed all requirements for graduation.
☐
A. Informal Warning:
Verbal or written informal warning.
☐
B. Additional Assignment:
Ethical decision making seminar and/or reflection paper assigned.
Formal Sanctions: A copy of this report and accompanying documents are placed in the student’s file. If an additional report(s) is/are
filed, this report may be submitted along with new information to the PASC. The appropriate office selected below is also notified.
☐
C. Formal Warning:
The report will be sent to the FCOP Office of Academic Affairs. The report
may be forwarded to the FCOP Professional and Academic Standards
Committee (PASC) and/or the UT Tyler Judicial Affairs Office.
☐
D. Academic Penalty:
Please indicate the specific academic penalty imposed.
☐ Additional Assignment:
☐ Assignment Grade Change:
☐ Other (describe):
☐
E. Internal Referral(s):
The report will be sent to the FCOP Professional and Academic Standards
Committee (PASC) for investigation and/or sanctions. The report may be
forwarded to the UT Tyler Judicial Affairs Office for investigation and/or
sanctions.
☐
F. External Referral(s):
The appropriate legal, regulatory, and/or professional authorities will be
contacted regarding this report. Please specify the agency:
Faculty Member’s Signature:
Date:
Faculty’s Full Name:
Email Address:
Student Response Required:
☐
I acknowledge the informal warning and agree (if applicable) to complete the additional assignment in the
timeframe specified.
☐
I accept responsibility for the actions described in this Professionalism Alert and accept the proposed
sanction(s). By accepting responsibility, I acknowledge that I waive my rights to any
other adjudicatory
process or appeal.
☐
I accept responsibility for the for the actions described in this Professionalism Alert, but I do not agree with the
proposed sanction(s). I request a formal hearing with the PASC regarding the sanction.
☐
I do not accept responsibility for the actions described in this Professionalism Alert. I request a formal hearing
with the PASC or, if appropriate, the UT Tyler Office of Judicial Affairs.
Student Comments:
You may attach an additional page if more space is needed.
Student’s Signature:
Date:
Student’s Full Name:
PLEASE SUBMIT THIS FORM TO THE OFFICE OF STUDENT AFFAIRS
ATTN: Dr. David Romerill• DRomerill@uttyler.edu • Fax 903.565.5504
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Completed 24 July 2020

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