Academic Integrity Report Form

Download and complete the following to make a formal report of an incident:

Report of Academic Misconduct 

Introduction: A graduate student who is guilty of academic misconduct is subject to both academic sanctions and disciplinary sanctions. Disciplinary sanctions are determined by the Dean of Graduate Studies or, if the case reaches the Graduate Council, by the Graduate Dean on the basis of the recommendation of an appointed subcommittee of Graduate Council. Academic sanctions are determined by the instructor of record. In cases in which the student maintains his/her innocence of the charges, the instructor is asked to await the final decision of the Graduate Dean before imposing these sanctions, but the sanctions are ultimately at the discretion of the instructor. Academic sanctions, like any other aspect of a course grade or evaluation, can be appealed only through the Graduate Division policies for academic appeals.

This form should be completed and signed by student and instructor and forwarded to the Graduate Dean along with copies of evidence. A copy of this form should be kept by the instructor and the student.

Instructor ____________________________ Dept._______________________

Ext.___________ Email: ____________________________

Instructor’s Campus Address: __________________________________________

Student_________________________________ ID#____________________

Department/Program _________________ Degree sought ______________________

Email ______________________________

Address _____________________________________________ Phone _____________

Quarter_____________________

Course (or relevant context of alleged misconduct) _______________________________

Date of Incident ___________________

Violation: ___ cheating ___ plagiarism ___ other (explain) ______________________

____________________________________________________________________

Instructor’s Analysis (attach separate sheet, if necessary)

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

Evidence Attached (please list)__________________________________________

Proposed Academic Sanctions: ___ additional work ___ re-examination

___ exclusion from course ___ change of grade (explain)* ______________________

___ no credit for work in question ___ inclusion of incident in studentÀs narrative evaluation

Instructor’s Comments (if any)________________________________________________

______________________________________________________________________

Student Comments:

__ I am guilty of these charges. (If so desired, student may give an account of any unusual or extenuating circumstances in the space below.)

__ I am not guilty of these charges. (Student is asked to give his/her account of the incident in the space below.)

Student comments: (Attach separate sheet if necessary.)

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

Student’s signature____________________________________ Date__________

Instructor’s signature__________________________________ Date__________

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