REPORT ON ALLEGED CASE OF ACADEMIC MISCONDUCT

Student Name: ___________________________ Student Number: _________________________

Student Email and Phone Number(s): ____________________________________________________

Professor/Invigilator: ________________________________________________________________

Course Number& Section/Course Title: __________________________________________________

Name(s) of Other Student(s) Allegedly Involved: __________________________________________

__________________________________________________________________________________

Student Number(s) of Other Student(s) Allegedly Involved: __________________________________

__________________________________________________________________________________

Date and location of alleged academic misconduct: _________________________________________

Incident: ( ) Mid-term Exam ( ) Final Exam ( ) Test ( ) Quiz ( ) Essay ( ) Assignment ( ) Other
Grade is worth ___% of final mark.

Professor/Invigilator’s description of incident:

___________________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
___________________________________________________________________________________

List and attach supporting documentation (with ALL relevant sections highlighted, where
appropriate):

_______________________________________________________________________________

Professor discussed the alleged misconduct with the student.

Date and Location: ___________________

Professor discussed the alleged misconduct with a Coordinator. Date: ______________

Professor asked student to contact Associate Dean within two weeks of discussing the alleged
misconduct with student: ( ) YES

Signed: ______________________________ Date: ____________________________

Professor/Invigilator

Revised: July 2015

 STUDENT RESPONSE TO ALLEGED CASE OF ACADEMIC MISCONDUCT

Student Name:____________________________ Student Number:_________________________

Student Email and Phone Number(s): ______________________________________________________

Course Number & Section/Course Title:

_________________________________________________________

The above named student is alleged to have committed an act of academic misconduct in the
circumstances described by the professor/invigilator on page 1 above.

Student’s description of incident:

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
___________________________________________________________________________

I have written and read the above description and agree that it represents my account of the incident. I
understand that signing in the space below does NOT mean that I acknowledge violating academic policy.

Student’s Signature: _________________________________________

Associate Dean’s Signature: ______________________________ Date:_________________

Voluntary Acknowledgement

Student: Please sign in space below if you admit violating academic policy

I, ______________________________________, acknowledge the above violation of academic policy

and fully understand the penalties outlined below.

1st offence normally results in:
2nd offence normally results in:
3rd offence normally results in:
0 on the assignment or examination, and a letter in your file.
0 in the course, a letter in your file, and a comment on your
transcript, with the potential for immediate suspension from the
college for a period of time.
expulsion from the college.

Case:____________________________________ Date Filed: _________________________________

Revised: July 2015