Unprofessional Behavior/Mistreatment Reporting Form

Unprofessional Behavior/Mistreatment Reporting Form

NOTE: This form is for students to raise concerns about the behavior of faculty or staff.

Dell Medical School will not tolerate mistreatment in any form. We do not take lightly your experience, and we appreciate your willingness to report it so that we can improve the learning environment at Dell Medical School.

These submissions are viewed by the Associate Dean for Student Affairs and the Associate Dean for Undergraduate Medical Education. If you are concerned about one of these Deans viewing your submission, you should directly contact the other Dean about your situation.

Your name is not required to submit. If you choose to provide your name, confidentiality will be preserved.

I believe I, or another medical student, experienced unprofessional behavior and/or mistreatment from an individual in a teaching role.

First Name

Last Name

May we contact you about this submission to gather additional information about the incident?

Select

Confidentiality

Submissions may be anonymous, but every effort will be made to ensure confidentiality of a reporter should they choose to provide their name. The University and Dell Medical School will not tolerate any form of retaliation against an individual who has made a good faith complaint of mistreatment. Individuals who believe they have been retaliated against for raising concerns of mistreatment pursuant to this policy should contact the Associate Dean for Undergraduate Medical Education and the Associate Dean for Student Affairs.

Behavior Examples

According to the Association of American Medical Colleges (AAMC), mistreatment – either intentional or unintentional – occurs when behavior shows disrespect for the dignity of others and unreasonably interferes with the learning process.

Examples of mistreatment include:

Sexual harassment
Discrimination or harassment based on race, religion, ethnicity, gender, or sexual orientation.
Humiliation
Psychological or physical punishment
Use of grading and other forms of assessment in a punitive manner

The individual in the role being reported*

First and last name.

The job title of the individual being reported*

Brief description of what occured*

Please provide a brief description of what happened. Be sure to include details such as the date, location, any witnesses.

Have you reported this elsewhere?

If you, or another person, spoke directly with the instructor or other course representative about this conduct, please describe the interaction and date it was addressed. Please note any persons you name may be contacted about this incident.

Thank you for your time and courage to report this incident.

If after this process is completed you are not satisfied with the outcome, you can contact the University Ombuds office or use any other University reporting tools.

Resource links coming soon!

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