Academic Integrity Reporting Form

NOTE TO STUDENT: If you have any questions about this procedure or about this form, please contact either the Dean of Seaver College or the Chairperson of the Academic Integrity Committee, who may be contacted through the Dean's Office.

NOTE TO FACULTY MEMBER: You must complete the Incident Summary in addition to items 1, 2, 3, 7, 8, and 9. Student must complete items 4, 5 and  10 (6 is optional).

Instructions:  Please complete this form on computer, then print and mail it to:
Chairperson, Academic Integrity committee
c/o Dean of Seaver College 

Incident Summary

Faculty member(s) involved: Ext. No.
Ext. No.
Ext. No.
Which course was involved?
Which semester and year? Semester

Year 

 

Student(s) involved: Student ID:
Student ID:
Student ID:

 

Violation Level:
(explanation) 
  		   
Recommended Sanction:

Note: All Level Three and Four violations must be heard by the AEC.

Student Plea: Guilty/No Contest Request Hearing

1. Date and description of incident.  
    (Your entire description must be visible in the box without scrolling in order to print properly).


2. Witness(es) to incident:


3. Faculty sanction recommended for Level One or Level Two violations:


___________________________________
Faculty Member's Signature
___________________________
Date

4. Please have the student fill out and sign the following statement: 

I, , understand that if I do not agree with Professor 's judgment (that I have violated the Seaver Academic Integrity Code) or with the sanction imposed, I may ask the chairperson of the Academic Integrity Committee or the Dean of Seaver College to arrange a formal hearing for my case. I understand that if I accept this sanction, this violation of academic integrity will be recorded with the Seaver Dean's office. Further, if any other such charge is filed against me by any faculty member while I am attending Seaver College, I understand that a formal hearing may be held. 

___________________________________
Student Signature
___________________________
Date

5. Does the student admit guilt in the offense and accept the sanction imposed? 

a. Yes       If "yes" is marked, student should fill out and sign the following statement:
I,, freely admit that I have violated the Seaver Academic Code of Integrity in Professor 's class during
Fall   Spring   Summer semester,  
and I do not wish to contest the sanction s/he has imposed. 

___________________________________
Student Signature
___________________________
Date


b. No If "no" is marked, student should fill out and sign the following statement:
I, , do not agree with Professor's judgment of this incident and/or the sanction s/he has imposed, and I wish to have a hearing with the Academic Integrity Committee. 

___________________________________
Student Signature
___________________________
Date


6. (Optional) Student's statement about the incident:
    (Your entire statement must be visible in the box without scrolling in order to print properly).


7. Description of the meeting with student about the incident, or statement of attempts to reach student to discuss incident:
    (Your entire description must be visible in the box without scrolling in order to print properly).


8. Has the student been informed by you of his or her right to appeal or dispute your decision on this incident?     Yes    No


___________________________________
Faculty Member's Signature
___________________________
Date



9. Professor's conclusions about the incident:
    (Your entire statement must be visible in the box without scrolling in order to print properly).



10. Student contact information:

Name:
Daytime Phone:
Local Address:
Email Address:
Student ID #
To Print Completed Form:
  • PC users:   press  "CTRL" + "P"
  • Mac users: press  "COMMAND" + "P"

 

 
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