| Student Name: |
_______________ |
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Course No: |
______________ |
| Student ID: |
_______________ |
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Course Name: |
______________ |
| Date of Incident: |
_______________ |
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Faculty Name: |
______________ |
| Term of Incident: |
_______________ |
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Faculty Phone/E-mail: |
______________ |
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| Brief description of violation (if necessary, additional sheets may be used). |
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| Brief description of discussion held with student(s). |
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| Sanction determined by instructor. |
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| _______________________________ |
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________________________________ |
| Student's Signature Accepting Sanction |
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Instructor's Signature Accepting Sanction |
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| SEND TO: |
| Frederick Whelan, Assistant Dean |
| Arts and Sciences Undergraduate Studies |
| 140 Thackeray Hall |