Dean of Students Office

Individual Reporting the Incident:
First Name: Last Name:

UFID (if student/faculty):

E-mail: Phone Number (10 digits):

Date of Incident: JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember 12345678910111213141516171819202122232425262728293031 20082009 Time: 123456789101112: 000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 AM PM

Location of Incident:

Witnesses to the Incident (please list all witnesses):

Were others involved in the incident (UFPD, Housing, EMTs, etc.)? If so, who:

Student who harmed/affected you:

Violations of the Student Honor Code (please check the incident that occurred):

Plagiarism
Unauthorized Use of Materials or Resources (Cheating)
Prohibited Collaboration or Consultation
False or Misleading Statement Relating to a Student Honor Code Violation
False or Misleading Statement for the Purpose of Procuring an Academic Advantage
Use of Fabricated or Falsified Information
Interference with or Sabotage of Academic Activity
Unauthorized Taking or Receipt of Materials or Resources to Gain an Academic Advantage
Unauthorized Recordings
Bribery
Submission of Paper or Academic Work Purchased or Obtained form an Outside Source
Conspiracy to Commit Academic Dishonesty

Violations of the Student Conduct Code (please check the incident that occurred):

Causing Physical or Other Harm to any Person
Sexual assault and sexual misconduct
Harassment
Obscene behavior
Hazing
Firearms or other weapons violations
Fire safety violations
Drug violations
Alcohol beverages violations
Conduct disruptive to the university community
Misuse or unauthorized possession or use of public or private property
Misuse or unauthorized use of university computer resources
Unauthorized entry to university facilities
Furnishing false information
Unauthorized electronic or digital recording
Violation of university policy
Violation of law
Obstruction of the university conduct process
Failure to comply with directive
Complicity in violating the student conduct code

Incident Description:

I agree that the above statement is true and accurate to the best of my knowledge. I understand that I may be contacted by Student Conduct and Conflict Resolution to provide further information or serve as a witness for a student conduct hearing.

Electronic Signature (type your name):