Initial Referral Form

Section 4.01(a) of the Honor Code provides the requirements for filing an initial referral.

Instructions: Please complete this form (attaching additional pages if necessary), put it in an envelope, place it in the mailbox of the Associate Dean for Administration and Student Affairs, Annamaria Nields (mailbox located in Suite 200)  If possible, please send an e-mail to to notify her that the form is in her mailbox.

Your name (please print): ___________________________

Year (1D, etc.): _______

Your e-mail address: ___________________________________________

Your phone number: _____________________________________

Name of student(s) you are referring: __________________________________________

Year of the student(s) (if known): ____________

Class or activity involved in the incident: __________________________________

Professor of that class (if applicable): ________________________________________

Date of the incident: __________________________________

Approximate Date the alleged violation was discovered: ____________________

Describe the conduct that you allege was a violation of the Honor Code (attach additional pages if necessary).