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Received
by University Judicial Officer on_________________
Sent
to Student on_________________
Sent
to Department Chair on______________
Sent
to Dean on_______________
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Student's
Name:________________________________________ SS#______________
Faculty Member's Name:_________________________________ Ext:
______________
Course Title:___________________________Semester and
Year___________________
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Date(s) of faculty student meeting(s)_______________.
Description of the incident:
(Please copy and attach any necessary evidence)
·
The student has been informed of his/her rights as described in
the CCSU Student Handbook, including the right to pursue a grade appeal.
Yes______ No______
·
The student acknowledges a violation of Academic Honesty. --
Yes____ No____
·
The Professor's sanction:
Professor's
Signature:________________________
Date:______________________
Academic Conduct Workshop:
Yes/No
Date:
Judicial Hearing:
Yes/No
Date:
Outcome:
Judicial Officer’s
Signature___________________________ Date_____________________
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