Mistreatment Reporting Form

The University of New Mexico School of Medicine is committed to promoting a respectful, inclusive, and positive learning environment, free of mistreatment for medical students, residents, and fellows.

Mistreatment may be either intentional or unintentional and 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; and the use of grading and other forms of assessment in a punitive manner.

1. What is your role at UNM?*
Select all that apply

2. Please select the statement that best applies:*

If you witnessed or heard about mistreatment, please indicate who was mistreated:

What is the name of the person who was mistreated?

How would you like to report this incident?
Every report to LEO is confidential within the limits of the law.** This means that we will not share the details of this case with anyone who does not need to know in order to address the mistreatment. All reports made to LEO are kept in a database that SOM faculty and administrators cannot access. The LEO team members with access to this database are not faculty members.

Please remember that UNM has very strong policies and protections against retaliation for reporting, and part of LEO’s role is to protect reporters from retaliation. Anyone who reports suspected misconduct, in good faith, is afforded whistleblower protection from retaliation by the University (see UNM Policy 2200: Reporting Suspected Misconduct and Whistleblower Protection from Retaliation).

**Please note: LEO is required by law to report violations of Title IX or Title VII to the Office of Equal Opportunity, even if reported anonymously.

YOU HAVE A CHOICE: to report anonymously or to give us your contact information:

1. If you report anonymously: We will address your concern to the best of our ability, but we won’t be able to ask you questions or to get more details to help us move forward with the case. We also won’t be able to keep you updated on the status of your case.

2. If you give us your contact information, that does NOT mean that we have to release your information to the person you’re reporting, or to anyone else. You can ask us to keep your identity to ourselves, and we have ways of opening investigations without sharing particular details if you want to keep your identity anonymous outside of LEO.

In this case, our first step will be to reach out to you to learn more about what you’re reporting. At that time, you can tell us if you want us to keep your identity anonymous. We will also be able to be in touch with you about how the case is progressing and we can tell you when the case has been closed, to the extent allowable by policy and law.

We are best able to effectively address mistreatment when we are able to ask clarifying questions directly to the reporters.

3. How would you like to report this incident?*

I would like to report anonymously I am willing to share my contact information with LEO

What is your first and last name?*

What is your email address?

What is your phone number? (123-456-7890)

Tell us about the mistreatment

4. What type(s) of mistreatment have you experienced, witnessed, or heard about?*
Select all that apply

Please select the type of gender or gender identity based mistreatment*
Select all that apply

Please select the type of race and/or ethnicity based mistreatment*
Select all that apply

Please select the type of sexual orienation based mistreatment*
Select all that apply

Please select the type of disability based mistreatment*
Select all that apply

Other: please describe the type of mistreatment*
You'll have the opportunity to share the specific incident below

Who mistreated the learner?

5. The full name of the person who mistreated me, or who I observed or heard about mistreating a learner is:*

6. What department does this person work in?

7. What is their role at UNM?*

Other, please specify:

What happened?

8. The setting in which the event occurred (i.e. rotation, classroom, meeting, rounds, laboratory, advising session, etc.):

9. Location of incident:

10. Date the incident occurred:

Is this a recurring incident?

11. Name(s) of observers or witnesses of the behavior:

12. Please describe with as much factual detail as possible the event and the mistreatment experienced:*
Please be as specific and explicit as possible. This helps ensure that the incident is handled appropriately.

13. This behavior negatively impacted my:
Select all that apply

Other negative impact, please specify

14. Attachments
Use this space if you wish to attach any documents, screen shots, etc.

Please review your responses before submitting.

Thank you for your time, and to ensure that your response is recorded, press the Submit button below.

Send me a copy of my responses

Email address