POSSIBLE BREACH OF EXAM RULES INCIDENT REPORT
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Complete all sections of this form electronically and email to breaches@nzqa.govt.nz.
Use the Tab key to navigate through the document
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Print out a copy of the completed form and sign
Place the printed, signed copy with any additional materials into a blue plastic bag. This then
goes inside a green E-pak.
Put the candidate’s answer booklets in the green E-pak to send to the marker as usual unless
the breach involves authenticity.
Candidate Name:
Candidate NSN:
School Name:
Exam Centre Code:
Examination:
Level: Level 1 (select one from drop-down box)
Standards:
______________________________________________________________________________
Multiple Candidate Breach (Enter candidate NSNs)
Candidate 2
Candidate 6
Candidate 3
Candidate 7
Candidate 4
Candidate 8
Candidate 5
Candidate 9
______________________________________________________________________________
Details
Date:
What happened:
Time of incident:
Were other candidates disadvantaged by this incident? Yes
If yes, please indicate to what extent:
Action taken:
______________________________________________________________________________
Materials included in the blue plastic bag with printed, signed copy of this report:
Put ‘x’ if
applicable
Any notes or additional materials taken from candidate(s)
iPods, translators, etc.
Exam room plan (who was sitting where), where applicable
Student scripts (where possible breach involves authenticity)
Additional Witness(es):
(Please enter names)
Exam Centre Manager Name:
Date:
Supervisor Name:
Date: