For assistance verifying the information on this form is correct, and to take into consideration previous student violations, please contact the Academic Advising Center, your campus director, or department chair before completing this form.


This report may only be shared with the individual to whom it pertains and with those within the university who have a legitimate need for the information on the report. Should the report name additional students, protect their privacy by redacting their name on any copies shared with other students.

Instructor & Course Information
Student Information
Describe the Incident

Include assignment, date, time, location, student's response.


May include frequency and degree of previous offenses, student's response.

Describe Supporting Documentation

Supporting documentation must be sent to Carolyn Brown ( Please summarize the documentation you will be sending after this form is submitted.

Disciplinary Action

By submitting this form, this incident and accompanying documentation will be filed for future reference and/or used for further action as needed. Upon your discretion or on repeated offenses, the student may be enrolled in the Plagiarism Prevention Program (if the situation is appropriate; see more information here:, participate in an advising session to understand the consequences of academic dishonesty, or referred to administration for disciplinary action. Before making a decision about further action, please reflect on the scope of the situation and consider discussing the incident with the student (if you have not already). If you are interested in seeking further action for this incident beyond your in-course consequences, please indicate so below. You will be contacted with more information about the options noted above.