Office of Student Conduct and Integrity
Indiana State University
Date of Meeting with Student
Course Number and 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 an egregious violation of the Academic Integrity Policy or there is an additional
violation. 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.(A Change of Grade Form must be processed to amend the original grade, if appropriate.)
Referral to the Office of Student Conduct and Integrity. (Students found in violation may be suspended or expelled and can have a permanent notation affixed to the official transcript indicating that an academic integrity violation occurred.)
Note: The student cannot drop a course with an academic integrity issue unresolved. 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 the Office of Student Conduct and Integrity, Hulman Memorial Student Union, room 821. The instructor provides a copy
to the student. The Office of Student Conduct and Integrity 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 ot the Office of Student Conduct and Integrity (extension 3800.)
back to top : Faculty Guide to Academic Integrity (PDF)
200 North Seventh Street, Terre Haute, Indiana, USA 47809-1902