Academic Dishonesty Report Form
(Senate: 11/29/07, 6/1/10; President: 1/30/08, 6/21/10)
For the purposes of reporting findings of academic dishonesty, the term ‘reporting party’ may refer probationary, tenured and temporary faculty, librarians, persons in academic administrative positions, counselors, coaches, or administrators of testing centers or another person in a position of authority over a student’s academic work. Teaching assistants, graduate assistants and staff members should report allegations of academic dishonesty to their authorized University supervisor. Reports shall address the activities of individual students rather than groups of students.
Please thoroughly review the University’s Academic Honesty Policy before completing this report. Attach all documentation in support of the findings of academic dishonesty and submit the report, with attachments to the Judicial Affairs Officer, Student Affairs Building, Room 117. (http://www.calstatela.edu/univ/stuaffrs/jao)
Student Name: _______________________________ CIN: ______________________
Student Phone Number:* ___________________________________________________
Student E-mail Address: * __________________________________________________
*For notification purposes only. No confidential information will be conveyed via e-mail or voice mail.
Class Title: _______________________________ Course#: _______ Term: _________
Reporting Party’s Name: ____________________________________
Campus Extension:* ____________
Reporting Party E-mail Address:* ______________________________
Assignment for which cheating/plagiarism is alleged: ____________________________
Date of incident: _______________
Description of incident: Please attach additional pages or supplementary report as necessary; also include copies of supporting documents, (e.g. copy of paper or exam).
Notes from discussion with student or reason for not meeting with student: (The reporting party and/or student may attach notes for submission to the Judicial Affairs Officer).
Academic Consequences imposed by reporting party: (Check all that apply.)
Failing grade on assignment
Failing grade in the course
Other (Please specify):_______________________________________________
In addition to any academic consequences assigned by the reporting party, administrative sanctions may be issued by the Judicial Affairs Officer. Please recommend as to whether or not you believe administrative sanctions should be considered, and the rationale:
Check all that apply:
I was unable to meet with the student.
Please provide reason: ________________________________________________________________
I have provided the student with a copy of this form and with copies of all supporting documentation.
The student disputes the allegation of academic and has provided evidence in support of his/her position. That evidence is also attached to this report.
Reporting Party’s Signature:________________________________ Date:___________