University of California                                     Santa Barbara

                           FACULTY REPORT FORM
                                   for
                      Academically Related Misconduct

   It is necesary to complete this form to report all instances of acade-
   mically related misconduct.  Make copy for your records and forward
   the original to the Office of the Dean of Students (Bldg 427, X 4467).

   Instructor ____________________ Department ________________ Ext.________

   Student ___________________________  Perm # ____________________________

   Course ____________________________

    Violation (date ________________):  __ cheating
                                        __ plagiarism
                                        __ other (explain) _________________

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    Every attempt should be made to contact the student before filing this
    form.  Please see pg. 38 of the Campus Regulations.

    Action taken by instructor:         __ written/verbal reprimand
                                        __ assignment of additional work
                                        __ re-examination
                                        __ exclusion from course
                                        __ change of grade (explain)* ______

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    Do you recommend that this student be brought before the Student
    Faculty Conduct Comittee?     __ yes       __ no

    If yes, please submit copies of the evidence (e.g. papers, exams, etc.).
    *If the course grade could be affected, please report a `NG' until the
    matter is resolved through the Dean's Office.

   Additional Comments:_____________________________________________________

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   Instructor's Signature ________________________________  Date ___________