Faculty Reporting:          

Location of Incident:       

Department:                       

Date/Time of Incident:    

 Phone #(s):                                                                                 

Course Title:                   

 Email/Campus Box #:                         

Course Reference #:        

Involved Students/ Persons

(Please specify the role of each listed person as a "witness," "victim," or "accused.")

Student Name/Role:         

Banner ID#                (if available)

 Student Name/Role:       

Banner ID#:               (if available)               

 Student Name/Role:        

Banner ID#:               (if available)

Type of University Violation

(Please indicate the appropriate category of the allegations.  The following violations are listed on pages 4, 6, & 7 of the UCO Code of Student Conduct.)

    Other:

Has contact been established with the student(s)? Yes No

How were the student(s) contacted?

Did student(s) have opportunity to voice their version of the incident?   Yes No                         

Did student(s) admit or deny responsibility for allegations?       Admitted Denied

Purpose of Report/Notice of Action  

(If student has accepted responsibility for violation or has been determined to be responsible for violation, then indicate the preferred action option below.  If student denies responsibility for alleged violation, then refer student to either Grade Appeal Process or forward this report as a formal complaint to Student Conduct Officer—S.C.O.)

1. Notice of Grade/Points Penalty 2. Notice of Class Failure 3. Informal Complaint

4. Formal Complaint to S.C.O.   5.Resubmit Assignment/Retake Exam

    Other or Desired Outcome:

(Please provide a detailed description of the alleged University violation and any actions that may have been taken.)