This form is to be submitted by the Associate Dean to summarize the informal/formal resolution of a student discipline case under Policy 71.

Student Information:
Last Name:
First Name:
ID Number:
Faculty: Applied Health Sciences Arts Engineering Environment Mathematics Science
Program:
Undergraduate or Graduate Student: Undergraduate Graduate
Year of Study: 1st 2nd 3rd 4th Other
Offence Number: 1st 2nd 3rd 4th Other

If more than one individual is involved, please fill in the same information as above here:

Person initiating charge:
Course:
Date of offence:
Date of Resolution/Decision:

Offence information:

Academic:
cheating plagiarism unauthorized co-operation or collaboration unauthorized aids or assistance unauthorized resubmission of work violation of examination regulations impersonation obtaining confidential academic materials theft of intellectual property academic or admission fraud altering, falsifying a relevant document misrepresentation misconduct in research contravention of statute other
If "other", please indicate:

Non-academic:
disruptive, dangerous, aggressive or threatening behaviour misuse of University resources mischief vandalism theft infringing unreasonably on the work of others violation of instructor's rules violation of safety regulations unauthorized use of equipment unethical behaviour contravention of statute other
If "other", please indicate:

Summary of Facts:

Aggravating/mitigating Circumstances:

Decision and Penalty:

Student has been placed on disciplinary probation: Yes No

Signature: _______________________________________________

Date:  ___________________________