Conduct Standards Violation Form Testing
Cosumnes River College
REFERRAL FOR STUDENT CONDUCT STANDARDS VIOLATION
* denotes required fields
Student's Information
*First Name:
*Last Name:
*Student ID#:
Phone/Cell:
Email Address:
Address:
Referent's Information
*First Name:
*Last Name:
*Email:
If you use your Los Rios email addresses you will receive a receipt for your records
Course Title:
Location of Incident:
The above mentioned student has violated one or more of the LRCCD Standards of Student Conduct as checked below:
Willful disobedience, disruptive behavior, profanity, or abuse of college personnel to directions of college official acting in performance of their duties.
Persistent serious misconduct.
Violation of college rules and regulations including those concerning student organizations, the use of college facilities, or the time, place and manner of public expression or distribution of materials.
Dishonesty, such as cheating, plagiarism or knowingly furnishing false information to the college
Unauthorized entry to or use of the college facilities
Forgery, alteration, or misuse of college documents, records or identification
Obstruction or disruption of teaching, or other authorized college activities
Theft of or damage to property or possession of stolen property belonging to the college, a member of the college community or a campus visitor
Misconduct which results in injury or death to a student or college personnel, lewd, indecent, or offensive conduct
Soliciting or assisting another to do any act which would subject a student to discipline
Assault or battery, sexual assault, abuse, or any threat of force or violence directed toward any member of the college community
Use, possession, distribution or being under the influence to alcoholic beverages, narcotics or dangerous drugs
Knowing possession or use of explosives, dangerous chemicals or deadly weapons
Knowingly access and without permission, alter, damage, copy, delete, destroy or otherwise use any data, computer program, computes computer system or computer netwrok
Smoking in area where smoking has been prohibited
First Incident
Date of 1st Incident:
(mm/dd/yy)
Was student advised of violation?
Yes
No
The violation(s) occurred as specifically described below:
Action Taken:
Was the student removed from class?
Yes
No
Date:
(mm/dd/yy)
Consultation with Area Dean/Supervisor:
Yes
No
Date:
(mm/dd/yy)
Second Incident
Date of 2nd Incident:
(mm/dd/yy)
Was student advised of violation?
Yes
No
The violation(s) occurred as specifically described below:
Action Taken:
Was the student removed from class?
Yes
No
Date:
(mm/dd/yy)
Consultation with Area Dean/Supervisor:
Yes
No
Date:
(mm/dd/yy)
*Action Requested
Referral for formal disciplinary action
General warning letter to student
You will be notified once this form is received by the Student Discipline Officer, Shannon Dickson, Dean of Counseling and Student Services. You may contact the office at (916) 691-7738
