ࡱ> u |&bjbjii 7xjxj5F  +++8c$+o9Z3Z49999999;>994)9!!!R9!9!!3>Z66+'258?90o9H5??,Z6Z6?n6!99 o9? :  QUEENS UNIVERSITY BELFAST FORMAL STATEMENT OF ALLEGATIONS FORM This form is for use by students, staff and other reporting individuals and should only be used if you wish to make an allegation of misconduct against a Queens University Belfast student. Please read the HYPERLINK "/directorates/AcademicStudentAffairs/AcademicAffairs/GeneralRegulations/AppealsConductandComplaints/Conduct/ConductRegulations/"Conduct Regulations and the HYPERLINK "/directorates/AcademicStudentAffairs/AcademicAffairs/GeneralRegulations/AppealsConductandComplaints/Conduct/StandardMisconductProcedure/"Standard Misconduct Procedure / HYPERLINK "/directorates/AcademicStudentAffairs/AcademicAffairs/GeneralRegulations/AppealsConductandComplaints/Conduct/SeriousMisconductProcedure/"Serious Misconduct Procedure before completing this form. You are strongly encouraged to seek advice and guidance from HYPERLINK "https://www.qubsu.org/AdviceSU/"SU Advice. Support is also available from the  HYPERLINK "/directorates/sgc/wellbeing/" Student Wellbeing Service. Allegations made anonymously will not be accepted. Section 1: Details of Reporting Person (your details) Full Name:Address for Correspondence:Tel no: E-mail:Relationship to Responding Student (if any)For Queens students only:Student Number:  Section 2 Details of student against whom you wish to make an allegation of misconduct (Responding Student) Full name: Students address (if known): Students School (if known):  Programme of study (if known): Year of study (if known):  Section 3: Details of Allegations Incident 1: Date of incidentTime of incidentLocation of incidentNames of people presentDescription of what happened (in chronological order) Description of any harm or impact caused by the incident Names and contact details of any witnesses for this incident **Please note that witnesses should provide witness statements on the HYPERLINK "https://forms.office.com/Pages/ResponsePage.aspx?id=6ner6qW040mh6NbdI6HyhsxB9YWHxklFjqHcF2OgVt9UMEQwQzk4S0dGNlo5WkdSMjA5OFUwSDVMTyQlQCN0PWcu"Witness Statement Form**Have you reported the incident to any external agent or service, such as the Police? Incident 2: (if applicable) Date of incidentTime of incidentLocation of incidentNames of people presentDescription of what happened (in chronological order) Description of any harm or impact caused by the incident Names and contact details of any witnesses for this incident **Please note that witnesses should provide witness statements on the HYPERLINK "https://forms.office.com/Pages/ResponsePage.aspx?id=6ner6qW040mh6NbdI6HyhsxB9YWHxklFjqHcF2OgVt9UMEQwQzk4S0dGNlo5WkdSMjA5OFUwSDVMTyQlQCN0PWcu"Witness Statement Form**Have you reported the incident to any external agent or service, such as the Police? Please outline any further incidents on a separate sheet, using the format above for each further incident e.g. incident 3, incident 4. Section 4 Supporting Evidence List of evidence attached (e.g. emails, texts, photographs, social media messages, videos) Please note that any evidence which is not in English must be accompanied by a translation Witness statements should be provided on the HYPERLINK "https://forms.office.com/Pages/ResponsePage.aspx?id=6ner6qW040mh6NbdI6HyhsxB9YWHxklFjqHcF2OgVt9UMEQwQzk4S0dGNlo5WkdSMjA5OFUwSDVMTyQlQCN0PWcu"Witness Statement Form Section 5 Desired Outcome The University has in place an HYPERLINK "/directorates/AcademicStudentAffairs/AcademicAffairs/GeneralRegulations/AppealsConductandComplaints/Conduct/InformalResolutionProcedure/"Informal Resolution Procedure, to facilitate informal resolution where appropriate and possible. This may include a Future Conduct Requirement between a Reporting Person and the Responding Student. Informal Resolution means that the matter will not be investigated under the Conduct Regulations, and no decision will be made by the University on the matter. Do you wish to seek informal resolution? (please tick)YesNo If you have answered no, please state below the outcome that you are seeking. Please be aware of the penalties available to the University set out in the HYPERLINK "/directorates/AcademicStudentAffairs/AcademicAffairs/GeneralRegulations/AppealsConductandComplaints/Conduct/ConductRegulations/"Conduct Regulations:  Section 6: Declaration By signing this form, you are declaring that: you have read and understood the HYPERLINK "/directorates/AcademicStudentAffairs/AcademicAffairs/GeneralRegulations/AppealsConductandComplaints/Conduct/ConductRegulations/"Conduct Regulations and the relevant  HYPERLINK "/directorates/AcademicStudentAffairs/AcademicAffairs/AppealsComplaintsandMisconduct/StudentConduct/" Misconduct Procedure; to the best of your knowledge, this form contains a complete and accurate account of all the factors relevant to the allegation of misconduct that you are raising; you understand that a copy of this form will normally be provided to the Responding Student(s) who is/are the subject of the allegation, or who is otherwise involved; you consent to this information and supporting evidence being disclosed to the members of staff involved in the misconduct process; any witnesses listed are aware that you have identified them as witnesses, and have consented to being contacted by the University; if you are a Queens student, you are aware that making a complaint which is found to be frivolous or vexatious may be deemed to be a breach of the HYPERLINK "/directorates/AcademicStudentAffairs/AcademicAffairs/GeneralRegulations/AppealsConductandComplaints/Conduct/ConductRegulations/"Conduct Regulations; if you are a Queens student or staff member, you are fit to engage with the HYPERLINK "/directorates/AcademicStudentAffairs/AcademicAffairs/GeneralRegulations/AppealsConductandComplaints/Conduct/ConductRegulations/"Conduct Regulations and Procedure. If you believe that you are not fit, you should contact HYPERLINK "mailto:appeals@qub.ac.uk"appeals@qub.ac.uk. Provided that the information has not already been disclosed as set out above, if you wish to withdraw consent to any information being disclosed, you may do so at any time by sending an email to  HYPERLINK "mailto:appeals@qub.ac.uk" appeals@qub.ac.uk Section 7: Using Personal Information The information you provide is to facilitate your appeal in line with the Interim Measures Regulations and Procedure. Our lawful basis to process your information is under Article 6(1)(e) completion of a public task. We will hold your information securely and in line with our retention schedule.To find out more about how we manage your information and your rights please visit HYPERLINK "/privacynotice/OtherAreas/ListofOtherPrivacyNotices/PrivacyNotice-General.html" \t "_blank"/privacynotice/OtherAreas/ListofOtherPrivacyNotices/PrivacyNotice-General.html By submitting this form, you are giving us permission to perform these actions. Signed: Date: The completed form should be sent by email to the Appeals, Conduct and Complaints Team ( HYPERLINK "mailto:appeals@qub.ac.uk" appeals@qub.ac.uk). This Team is also able to provide advice on the HYPERLINK "/directorates/AcademicStudentAffairs/AcademicAffairs/GeneralRegulations/AppealsConductandComplaints/Conduct/ConductRegulations/"Conduct Regulations.      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