Academic Misconduct Incident Report
MUST BE COMPLETED WITHIN TEN WORKING DAYS OF DISCOVERY OF INCIDENT
(Click HERE for the printable PDF version)
Date of incident: ___________________ Date completed: ___________________
Student Name_____________________________________
Social Security #___________________________________
Faculty Name _____________________________________Phone _________________
Department ________________________________________ E-mail________________
Course Name _________________________________ Section _____ Semester ______
Explanation of incident: (Only state the facts. Attach additional pages as necessary.)
Student’s explanation of incident (if desired):
Meeting outcomes:
Charge(s): ________________________________________________________________
Recommended sanction:
8/02
Academic Misconduct Incident Report - Page 2
Both parties must read the following statements and initial each. Faculty Student
1. The student has been informed of his/her right to appeal either the
charge of misconduct or the recommended sanction to the Director of
Student Life. 1. ______ ______
2. a) I agree to the charge(s) presented in this document. 2a. ______ ______
OR OR
b) I do not agree to the charges and this case will be handled
through a formal hearing. 2b. ______ ______
3. a) I agree to the sanction stated in this document in lieu of an
administrative or panel hearing. 3a. ______ ______
OR OR
b) I do not agree upon the sanction; therefore, the sanction will be
determined by a hearing. 3b. ______ ______
4. I understand that the student has the right to rescind this agreement
within (5) five working days of its completion by submitting a written
statement of rescission to the Director of Student Life. 4. _______ ______
Failure to abide by the agreed upon sanction will result in formal
procedures through the college judicial system.
This information will become a matter of record and could be used
by a hearing panel or administrator in the event a future incident of
academic misconduct.
Student Signature _____________________________________________ Date _______________________
Student’s current mailing address: ____________________________________________________________
_______________________________________________________________________________________
Student’s current telephone number: _________________ Student’s current email address ________________
Faculty Member’s Signature: _______________________________________ Date_________________
The Director of Student Life will review the judicial records of the student involved in the incident. If previous Academic
Misconduct Incident Reports are on file, the Director may contact the student to begin the Formal Resolution Procedure.