APPENDIX B

ACADEMIC DISHONESTY INCIDENT FORM

 

Name of student: ___________________________________________UM ID# ____________

                                  Last                              First                        MI

 

Name of Instructor_____________________________________________________________

                                  Last                              First

Office Address: _______________________________________________________________

Office Phone: _________________________________________________________________

Course name and number: _______________________________________________________

Place and time where incident occurred: _____________________________________________

____________________________________________________________________________

Brief statement of incident (use attachments if necessary): ____________________________________________________________________________

____________________________________________________________________________

Instructor’s actions: _____________________________________________________________

____________________________________________________________________________

Does the instructor recommend that this incident be referred to the Justice Council for further consideration?

Yes ( )   No ( )

 

Instructor’s signature: ____________________________________________________

Student’s signature: _____________________________________________________

                       

Send copies:   Department Chair

                                              Dean of the College/Division where violation occurred

                                              Provost and Vice President for Academic Affairs

 

STUDENT BE INFORMED that further penalties may be recommended. The Provost and Vice President for Academic Affairs will recommend that the Justice Council consider this case (1) upon instructor recommendation or (2) if the student charged has a record of past violations of the Student Conduct Code even though the instructor did not recommend the case for further consideration.