Academic Dismissal/Integrity Incident Report Background InformationName First Last Your position/title: PhoneEmail Campus (Location of Incident)(Required) Hall Campus Barrow Campus Dawson Campus Forsyth Campus Jackson Campus Other-Adult Ed Other Date of Incident(Required) MM slash DD slash YYYY Time of Incident Hours : Minutes AM PM AM/PM Involved PartiesName First Last Student ID number (910#) PhoneEmail Add Another Party Yes No Additional Party InformationName First Last Student ID number (910#) PhoneEmail Incident Specific InformationName of program / course / term (for example: English / ENGL 1101 / 202112)(Required) Narrative of Incident (addition information needed can be attached)(Required)Requested course of action:(Required) Award a zero for the assignment (faculty decision, student has the right to appeal) Assign a failing “F” grade for the course (faculty decision, student has the right to appeal) Recommend dismissal of the student from their current program of study. Supporting DocumentationFilePhotos, video, email, and other supporting documents may be attached below. 32MB maximum total size. Attachments require time to upload, so please be patient after submitting this form.Max. file size: 8 MB.NameThis field is for validation purposes and should be left unchanged.