UNIVERSITY OF CALIFORNIA, MERCED FACULTY REPORT FORM FOR ACADEMIC MISCONDUCT – MULTIPLE STUDENTSOffice of Student Rights and Responsibilities – Kolligian Library Suite 113 DisclaimerThe Academic Honesty Policy (AHP) of the Academic Senate requires instructional faculty to complete this form to report all instances of academic misconduct. Please make one copy for your records, one copy for the Dean/Chair of your department/school/college/division and submit the original to Student Rights and Responsibilities - Kolligian Library Suite 113. This form is for similar alleged violations with multiple students. Instructor Information Instructor Name * School * Campus Phone Number Email Address * Course Name * Course Number * 1st Student & Incident Information Student Name * Student ID# Date of Incident * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20232024202520262027 Cheating Collaboration Plagiarism from internet Plagiarism from published sources Plagiarism from another student Theft/Tampering with Exam or Homework/Lab Falsified Information Other... Type of Incident Other... Assigning failing grade for course Assignment of additional work or re-examination Assigning failing grade or zero for piece of work Lowering the grade for the piece of work Assigning failing grade for the course with additional notation placed on student’s transcript – Grade resulted from a violation of the Academic Policy Other... Action taken by Faculty Other... Date student notified * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20232024202520262027 In person Via email Via phone Other... How student was notified Other... Responsibility Statement Yes No Other... Student admitted to the incident and accepted the above sanctions. Other... 2nd Student & Incident Information Student Name * Student ID# Date of Incident * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20232024202520262027 Cheating Collaboration Plagiarism from the internet Plagiarism from published sources Plagiarism from another student Theft/Tampering with Exam or Homework/Lab Falsified Information Other... Type of Incident Other... Assigning failing grade for course Assignment of additional work or re-examination Assigning failing grade or zero for piece of work Lowering the grade for the piece of work Other... Action taken by Faculty Other... Date student notified * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20232024202520262027 In person Via email Via phone Other... How student was notified Other... Responsibility Statement Yes No Other... Student admitted to the incident and accepted the above sanctions. Other... If there are more than 5 students involved, click on 6th thru 10th students below to add additional student information Please describe the alleged incident(s) in detail associated with each student. * Please describe the incident(s) in detail associated with each student. For example, Billy Joe copied Jane’s Adams exam answers, Sally Jones plagiarized from the internet. Copies of CorrespondencesAs the instructor of record for the course, you must provide written notice to the student(s) and give them the opportunity to respond. Copies of correspondence with student(s) must be submitted to your dean/chair of the Department/School/College/Graduate Division and Student Conduct with this form. Please submit email correspondance(s) in support of each alleged incident and any correspondence with the respective student(s). * Please email any documents larger than 2MB to studentconduct@ucmerced.eduFiles must be less than 2 MB.Allowed file types: gif jpg png bmp eps tif pict psd txt rtf html odf pdf doc docx ppt pptx xls xlsx xml avi mov mp3 ogg wav. Please submit the document(s) in question Please email any documents larger than 2MB to studentconduct@ucmerced.eduFiles must be less than 2 MB.Allowed file types: gif jpg png bmp eps tif pict psd txt rtf html odf pdf doc docx ppt pptx xls xlsx xml mp3. Please submit any support documentation Please email any documents larger than 2MB to studentconduct@ucmerced.eduFiles must be less than 2 MB.Allowed file types: gif jpg png bmp eps tif pict psd txt rtf html odf pdf doc docx ppt pptx xls xlsx xml mp3. Please submit any support documentation Please email any documents larger than 2MB to studentconduct@ucmerced.eduFiles must be less than 2 MB.Allowed file types: gif jpg png bmp eps tif pict psd txt rtf html odf pdf doc docx ppt pptx xls xlsx xml mp3. Additional alleged incident and any correspondences Please email any documents larger than 2MB to studentconduct@ucmerced.eduFiles must be less than 2 MB.Allowed file types: gif jpg png bmp eps tif pict psd txt rtf html odf pdf doc docx ppt pptx xls xlsx xml mp3. Additional alleged incident and any correspondences Please email any documents larger than 2MB to studentconduct@ucmerced.eduFiles must be less than 2 MB.Allowed file types: gif jpg png bmp eps tif pict psd txt rtf html odf pdf doc docx ppt pptx xls xlsx xml mp3. Additional alleged incident and any correspondences Please email any documents larger than 2MB to studentconduct@ucmerced.eduFiles must be less than 2 MB.Allowed file types: gif jpg png bmp eps tif pict psd txt rtf html odf pdf doc docx ppt pptx xls xlsx xml mp3. Additional alleged incident and any correspondences Please email any documents larger than 2MB to studentconduct@ucmerced.eduFiles must be less than 2 MB.Allowed file types: gif jpg png bmp eps tif pict psd txt rtf html odf pdf doc docx ppt pptx xls xlsx xml mp3. Additional alleged incident and any correspondences Please email any documents larger than 2MB to studentconduct@ucmerced.eduFiles must be less than 2 MB.Allowed file types: gif jpg png bmp eps tif pict psd txt rtf html odf pdf doc docx ppt pptx xls xlsx xml mp3. Additional alleged incident and any correspondences Please email any documents larger than 2MB to studentconduct@ucmerced.eduFiles must be less than 2 MB.Allowed file types: gif jpg png bmp eps tif pict psd txt rtf html odf pdf doc docx ppt pptx xls xlsx xml mp3. Given confidentiality laws and UC Policies, students should only be allowed to see the section which pertains to that student. Instructor's SignatureThis serves as a legal electronic signature. Electronic Signature * Tenured or Tenured Track Adjunct Graduate or Teaching Assistant Other... Campus Classification Other... Confirmation Info - The Office of Student Conduct will send you a PDF of this report as confirmation. The PDF can be utilized for reporting to others. If you have any question, please contact Doug Zuidema at 228-4552 or via email at studentconduct@ucmerced.edu CAPTCHAThis question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
