Student Name:

Student University ID: (Student Email)

Faculty Name:

Faculty Email:

Faculty Phone:

Department:

1. Course in which the incident occurred:

2. Date of the incident:

3. List of Witnesses & Roles
(if applicable)

4. Nature of the alleged offence intended to gain unfair academic advantage: Cheating Plagiarism Other (please describe)

5. Breifly describe the incident and, if any, subsequent investigation. How did you discover the incident? What events did you observe? What statements were made by the persons present?

6. What actions did you take to sanction the student?
 
 
 
 
 
None
Consulted student
Reduction in assignment grade
Reduction in course grade
Other (please describe)

7. In your assesment, did the student understand that he/she was committing and act of academic dishonesty? Probably did understand Probably did not understand

8. Do you include a statement regarding academic dishonesty in your course documents? Yes, in the syllabus Yes, on individual exams or assignments No

9. Resolution Options:
Based on this incident alone, do you recommend that the Office of Student Rights & Responsibilities issue a warning letter or file a formal charge(s)? Issue Letter File Formal Charges

10. Additional Comments: