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*Last Name : |
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*First Name : |
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Are You ... |
Student
Staff
Faculty
Community |
*Name of School, College,
Department, or Community: |
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Title: |
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10 Digit University ID #: |
(This is not your social security Number.) |
*E-mail: |
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*Telephone #: |
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Is This ... |
Academic Misconduct
Personal Misconduct
Not on University Property |
Date of Incident: |
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(mm/dd/yyyy) |
Name(s) of
Person(s) Involved: |
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Did You
Follow Up
With the Student(s)?:
(Check ALL That Apply) |
I have NOT contacted the student yet.
(Verbal) Spoke to student in person
(Verbal) Spoke to the student by telephone
(Written) Via U.S. Mail
(Written) Via e-mail |
Course Name/Title: |
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Course Number: |
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Faculty Member
Teaching the Course: |
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*Summary of Allegations
Include Outcome:
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