Suspected Violation of Honor Code: Complaint Form Name of student: ________________________________________________________________ General category of suspected Honor Code violation: □ cheating □ conspiracy & collusion □ fabrication
□ plagiarism □ falsification of records □ false accusations
□ bribery □ computer misuse □ misrepresentation
□ HIPAA violation ‐breach of confidentiality and/or security
□ failure to report observed violations □ unprofessional conduct When suspected violation took place: Date: _______________________ Time: _________ AM/PM List any witnesses to the suspected violation: ___________________________________________________________________________________
___________________________________________________________________________________ Please comment on the exact circumstances of the suspected violation and the nature of your personal observation. Describe any action you took. Attach additional sheets and/or written documentation, if necessary. _______________________________________________________________________
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_______________________________________________________________________ I, ________________________________________________________ (print name), attest that the above information is true and accurate to the best of my knowledge. Signature: __________________________________________________ Date: _________________ Once completed, submit this signed form to the Office of Academic Affairs AHC2 – 660W2. Attention: Executive Associate Dean for Academic Affairs. Thank you. [04‐28‐15} __________________________________________________________________________________________ OFFICE USE: Date received by FIU HWCOM Office of Academic Affairs: ____________________________ Meeting date with student: ___________________ Disposition: □ dismissed □ remediation □ informal resolution □ formal resolution (Honor Council deliberation)