Academic Integrity Referral Form

Lead Individual Referring Case

(Faculty, Staff, or Student)

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Your Full Name:

Your Position/Title:

Your Phone Number:

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Office (preferred) or Local

Your Email Address:

Email address must be of a valid format.

Office or Local Address:

Code Violation(Required):

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Select primary nature of the allegation (additional violations will be determined by a staff member)

Type of Assignment(Required):

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Major: exam, research paper, project or several minor. Minor: homework, in-class exercise, low-point

Date of incident(Required):

This field is required.

Time of incident:

Referring College(Required):

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Course and Section:

Involved Parties

Please identify any/all individuals who may have been involved in this incident and would be able to attest to facts [ex: student(s) being referred, eye witnesses, etc.] *Do not include Teaching Assistants or other faculty members in this section.

Name or Organization

Select Role

ID Number

Phone number

Email address

Incident Information

1). Please describe the incident exactly as it occurred. Include all factual information that may be relevant, including the type of academic exercise or assignment.(Required) This field is required.

2). Please provide the name and contact information of any other faculty/staff members who may be involved in this referral along with their role (i.e. Teaching Assistant, Department Chair, etc.).(Required) This field is required.

3). I have supporting documents relating to this case (should be attached to this referral below)

Yes No

This field is required.

4). As outlined by Part 5 of the Code of Academic Integrity, the expected sanction for a major graded assessment of an undergraduate student shall be a grade of "XF" in the course (failure in the course due to academic misconduct as denoted on the transcript). The expected sanction for a graduate student shall be dismissal from the University (suspension or expulsion). No grade should be given for any coursework referred to this office without notification from the Office of Student Conduct (a grade of "J" should be entered for any final grade until the case is resolved).(Required)

By checking this box, I affirm that I have read the information above as it relates to sanctions for students found responsible for violating the Code of Academic Integrity.

You must make at least one selection.

5). According to the Code of Academic Integrity, the Student Honor Council and the Office of Student Conduct have the responsibility to determine sanctions. Determining an appropriate sanction is done in consultation with the reporting party. Recommendations made by faculty/instructors are closely reviewed and considered by the Student Honor Council and Office of Student Conduct Staff. In the box below, please share any information regarding this incident you think should be taken into account (e.g. admission of responsibility, display of remorse, confrontational behavior, etc.) when determining the sanction:(Required) This field is required.

Please attach a copy of the syllabus and/or the assignment instructions.(Required)

I attached a copy of the syllabus and/or the assignment instructions.

You must make at least one selection.

Supporting Documentation

Please attach any evidence (ex: examinations, assignments, emails, course syllabus, etc.) which may support allegations of misconduct. PDF Format is preferred and documentation should be clearly labeled. Other supporting documentation may be emailed to studentconduct@umd.edu. We recommend you retain any original documentation until the case has been completely resolved. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Email me a copy of this report

Lead Individual Referring Case

Involved Parties

Incident Information

Supporting Documentation

Submission