Academic Integrity Violation Form

Division of Academic Affairs

DEPARTMENT CHAIR: Do NOT approve or decline until you complete the section titled "Department Chair Level" according to these steps:
1. Select "Edit" on the blue menu located at upper right of entry.
2. Scroll to Department Chair Level section > Complete all fields.
3. Scroll to bottom of page and select "Save Changes".
This form is to be completed after the faculty member has given the student 5 days to respond to the charge.
Student's Name Student's Name First Last
Student's Email
Student's 800 Number
Must be 9 digits. Currently Entered: 3 digits.
Student's Major
Instructor (or person filing report) Instructor (or person filing report) First Last
Instructor's Office Phone Number Instructor's Office Phone Number - ### - ### ####

We ask for this number in case more information is needed.
Instructor's Email
Department/Unit
Department Chair's Name Department Chair's Name First Last
Department Chair's Email
Violation Details
Violation Level
Violation Description - Do not use special characters
Must be between 5 and 250 words. Currently Entered: 0 words.
Upload the evidence of the violation
maximum 5 files whose total size may not be more than 10MB
filenames should not contain more than one period (.)
Date Violation was Discovered Date Violation was Discovered / MM / DD YYYY
Date Student was Emailed about the Violation Date Student was Emailed about the Violation / MM / DD YYYY
Date of Conversation with Student Date of Conversation with Student / MM / DD YYYY
Student Response
Sanction to be imposed
Other sanction to be imposed (Do not use special characters)
Must be between 1 and 100 words. Currently Entered: 0 words.
Check the box if applies (only applicable for level 3 violations)

Check the box if applies (only applicable for level 3 violations) Recommend dismissal from the major or program
Instructor, type your signature into the box below.

I understand this is a legal representation of my signature.
Date this form was initiated Date this form was initiated / MM / DD YYYY
Select "Submit" to forward this form to your Department Chair.

Copies will be emailed to you and the student.
Department Chair Level

Department Chair Review Level must be completed within 5 business days.
Department Chair's Determination
Additional Department Level Sanctions

Additional Department Level Sanctions Yes No
Department Level Sanctions to be Applied
Upload a file that supports reason for additional sanction(s) (e.g., student handbook, codes of ethics)
maximum 5 files whose total size may not be more than 10MB
filenames should not contain more than one period (.)
Reference - Web Site 1
Reference - Web Site 2
Date of Department Chair Determination Date of Department Chair Determination / MM / DD YYYY
Attention Student: You have a right to appeal (within 10 business days) to the following Dean/ Dean's Designee.

Academic Integrity Violation Form

This form is to be completed after the faculty member has given the student 5 days to respond to the charge.

Violation Details

Select "Submit" to forward this form to your Department Chair.

Department Chair Level