PACIFIC LUTHERAN UNIVERSITY

ACADEMIC DISHONESTY REPORT FORM

Instructor Date of Report

Course Department and Number Course Name

STUDENT(S) INVOLVED

Name Student ID Number Name Student ID Number

___

___

SUMMARY OF FACTS

Please complete as specifically as possible all sections which apply.

Date of Incident(s)

Location of Incident(s)

Coursework in which dishonesty is suspected

Please indicate what percentage of course grade this work represents.

Term Paper ______Final Examination

Lab Other Examination

Oral Presentation Other

Witnesses to the Incident(s)

Name Student ID Number Name Student ID Number

__

__

Do you wish to convene an Academic Dishonesty Hearing Panel? YES __ NO

An Academic Dishonesty Hearing Panel will automatically be convened if there is already another report on file.

Please provide a complete summary of the incident. Your summary must include the following:

· how you became aware of the misconduct;

· a description of the misconduct (see Academic Integrity Policy for violations);

· a description of any physical evidence (attach evidence if available);

· if appropriate, a diagram of the locations of the student(s) involved and witnesses if applicable;

· evidence which may support allegations of plagiarism, including photocopies or citations of original materials.

Signature of Reporter Date

Please submit this form and all evidence to the Chair of the Campus Life Committee.