Person filing this Complaint (“Complainant”):
Name Telephone
Number
Address Department
Person(s)
and/or organization against whom this Complaint is filed (“Respondent(s)”):
Name Student
Number Telephone
Number
Address
Brief
statement of facts on which charge of misconduct is based (Attach supporting
documentation as appropriate).
Misconduct
Charged
q
1. Copying another student’s test paper
q
2. Using unauthorized material on test
q
3. Collaborating on test
q
4. Obtaining unadministered test
q
5. Selling/giving away unadministered test
q
6. Bribing to obtain unadministered test
q
7. Substituting/allowing substitution to take test
q
8. Misrepresentation of someone else’s work as your
own
q
9. Supplying another student work to fulfill academic
requirements
q
10. Plagiarism
q
11. Submitting work previously used to fulfill
academic requirements
q
12. Falsifying information
q
13. Cheating in any other form
q
14. Other
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Does the
faculty member filing this form want to initiate disciplinary procedures
against the respondent? __Yes __No
___Possibly
at a later date if circumstances warrant
Has the
faculty member communicated with the student? ___Yes ___No
_______________________________________________Signature
of
Form #1/03