KSU Office of Judiciary Programs
Student Academic Misconduct Incident Report
please print this form and return it to the Office of Judiciary Programs
For directions on reporting incidents of academic misconduct and completing this form, click HERE.
Faculty Name: _________________________________________________ Date: _________________________
Department:____________________________________________________ Phone: ________________________
Student Involved in the Misconduct:
Name:_________________________________________________________________
KSU ID#: ______________________________________________________________
Misconduct Occurred:
Course Name:_________________________________ Section __________ Semester: ________________
Explanation
of Incident: (Attach additional pages, if needed)
Remedy
Agreed upon (if any): ____________________________________________________________________
Deadline for Completion (if applicable): ____________________________________________________________
Follow-up Action (if any): ______________________________________________________________________
_______________________________________________________________________________________________
The above is a true and accurate reflection of the situation as it occurred. We agree to the above stated remedy in lieu of a hearing before the University Judiciary. Failure to abide by this agreement may result in formal procedures through the University Judiciary. We understand that this information will become a matter of record with the University Judiciary Program and could be used by a hearing panel in the event a future academic misconduct incident occurs.
- Student Signature _______________________________________________ Date: _________________
Faculty Signature
_______________________________________________ Date: _________________
For Judiciary Program Office Use Only
Received:______________________________________________ File Number ____________________
Follow up action (if any): _______________________________________________________
_______________________________________________________________________________________________