College Code of Conduct / Academic Misconduct Intake Form

Student Name

First Name

Last Name

Year in School

e.g. sophomore or professional school or PhD candidate

Student Home Address

Student Phone

(###)

###

####

Student's Personal Email

Student's School/University Email

Parent Name

Name of parent /guardian if involved

First Name

Last Name

Parent Email

If parent is involved

Parent Phone

If parent is involved

(###)

###

####

Referral Source

Adverse Parties

Witnesses

Please include the full names of any school employees, students, or third parties that may have been witnesses if applicable

Name of College / University Attending / Program

Type of Pending Sanction

Please select all options that apply

Academic Misconduct

Code of Conduct

Not Sure

Has a Hearing Been Scheduled or Already Held?

Dates of Any Hearings (Either Held or Scheduled)

Brief Description of What Happened