Appendix II
Student Judicial Programs Indiana State University
Date of Meeting with Student
Department
Course Number and Name
Student's Name
Student's ID Number
This report is an informal record. The report may become part of a formal record if the above-named student is accused of additional violations of the Academic Integrity Policy. The report will not be released to any persons or agencies external to the University unless compelled by a civil or criminal court order.
1. Brief description of the violation (i.e. plagiarism, cheating on a quiz or examination, etc.)
Date of Occurrence:
2. The academic sanction to be assigned by the instructor (check all that apply): Grade penalty for the test or assignment Grade penalty for the course Additional course assignment to replace the academic exercise and allow a new grade to be assigned.
Instructor
Date
Phone
Department Chairperson
Note: The student cannot drop a course with an academic integrity issue unresolved. The academic integrity coordinator or the appropriate associate dean will have a dropped student's name restored to the course at the end of the term when an academic penalty is to be imposed. Complete, print, sign, and deliver this form to Student Judicial Programs, Hulman Memorial Student Union, room 821. The instructor provides a copy to the student. Student Judicial Programs will forward a copy of the form to the appropriate academic dean. Assistance with academic integrity questions may be referred to the appropriate associate dean, the academic integrity coordinator in the Office of Academic Affairs (extension 2304) or Student Affairs (extension 3888), or Student Judicial Programs (extension 3800.)
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