For alleged violations of the Academic Integrity policy, as dened in The Student Code of Conduct
Faculty Name & Department: _______________________________ Date:_______________
Student’s Name: _______________________________________ YSU Banner ID:______________________________
Violation description: (Please attach statement with additional information.)
Warning: __________________________________________________________________________________
Lowering the grade on the exam, paper, or assignment:_____________________________________________
Lowering the nal grade:______________________________________________________________________
Other: ___________________________________________________Due: ________________________
Request additional action from the Academic Grievance Subcommittee, such as removal from a
course, suspension, or expulsion: ______________________________________________________________
By signing this form, I:
Acknowledge that the conduct process and my rights within that process have been reviewed with me,
including that I have ve (5) University working days to sign and return this form.
Have the option to meet with my Departmental Chairperson and College Dean prior to signing this form.
Acknowledge that I was given the ability to inspect and review all relevant information regarding the
violation(s) in question.
Voluntarily waive my right to a hearing regarding these charges and accept this agreement as nal
resolution of this matter.
Understand that if I fail to meet any of the conditions listed above, I may be subject to further disciplinary
action and/or an administrative hold may be placed on my account.
Understand this report will be forwarded to The Oce of Student Conduct for review.
Understand that refusal to sign this document or failure to respond will result in a referral for an Academic Grievance
I agree to the charge: I agree to the sanction:
______________________________________ ______________________________________ ________________
Student Signature Student Signature Date
Student did not respond. Student declined to sign.
______________________________________ ______________________________________ ________________
Faculty Member Name Faculty Member Signature Date
*I acknowledge receipt of this form.
______________________________________ ______________________________________ ________________
Chairpersons Name Chairpersons Signature Date
______________________________________ ______________________________________ ________________
Deans Name Deans Signature Date
A letter will be emailed to your YSU email address, which will serve as the formal acknowledgement of this agreement.