Attachment III

Texas State University-San Marcos

Honor Code Review Form

Name of Student _________________________________________________________ ID# _____________________________

Department ________________________________________ Course# ________________ Semester _____________________

Summary of Facts to Constitute Violation ______________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________

(add additional pages if necessary)

 Date ______________________________ Time _________________________ Place _________________________________

Description of Evidence ____________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________

Course Professor or Instructor _______________________________________________________________________________

Decision of Faculty Member ____________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________

Acceptance of Administrative Disposition

I, the student whose signature appears below, DO accept the decision appearing above, I accept administrative disposition of the allegation against me in accordance with the Official Texas State Code of Student Conduct, and I knowingly and willingly WAIVE my rights to a hearing of the Honor Code Council and the right to appeal to the dean and the Provost/VPAA. I do understand that additional sanctions are/are not (circle one) being recommended by the faculty member to the Dean of Students Office and my acceptance of this academic sanction does not constitute a waiver of any rights of due process regarding any additional sanctions that may be imposed.

___________________________________________________ ________________________

Signature of Student Date

___________________________________________________ ________________________

Faculty Member Date

Non-Acceptance of Administrative Disposition

I, the student whose signature appears below, DO NOT accept the decision appearing above, and I DO request a hearing of the Honor Code Council in accordance with the UPPS No. 07.10.01. I understand that I have the right to appeal the decision of the Council to the appropriate dean and to the Provost/VPAA. I do understand that additional sanctions are/are not (circle one) being recommended by the faculty member to the Dean of Students Office and my non-acceptance of this academic sanction does not constitute a waiver of any rights of due process regarding any additional sanctions that may be imposed.

___________________________________________________ ________________________

Signature of Student Date

___________________________________________________ ________________________

Faculty Member Date

xc: Student

AVPAA

Chair of Honor Code Council