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?
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Select all that apply
I am a medical student
I am a resident or fellow
I am a faculty member
I am a staff member
I am another member of the care team
I am an undergraduate student in an HSC lab
I am an graduate student in BSGP, CCTS, or MSCR
I am a post-doc
2. Please select the statement that best applies:
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I have been the subject of mistreatment.
I have witnessed an incident of mistreatment.
I have heard about an incident of mistreatment severe enough to bring to the attention of the administration; however, I acknowledge that I am not a party directly associated with the incident and I may not receive feedback regarding it.
I am uncertain if I or someone else has been mistreated, but I would like to report an incident.
If you witnessed or heard about mistreatment, please indicate who was mistreated:
Medical student
Resident or fellow
Faculty member
Staff member
Another member of the care team
Undergraduate student in an HSC lab
Graduate student in BSGP, CCTS, or MSCR
Post-doc
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?
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I would like to report anonymously
I am willing to share my contact information with LEO
What is your first and last name?
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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
Verbally abused
Publicly humiliated
Threatened with or/or subjected to physical harm
Neglected and/or left out
Made to perform physical services
Threatened with retaliation or retaliated against
Subjected to unwanted sexual advances
Mistreated based on gender or gender identity
Mistreated based on race and/or ethnicity
Mistreated based on sexual orientation
Mistreated based on disability
Subjected to offensive behaviors based on personal beliefs or personal characteristics other than gender, race/ethnicity, sexual orientation, or disability
Other
Please select the type of gender or gender identity based mistreatment
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Select all that apply
Subjected to offensive remarks or names related to gender or gender identity
Denied opportunities and/or received lower evaluations or grades because of gender or gender identity rather than performance
Other offensive behaviors related to gender or gender identity
Please select the type of race and/or ethnicity based mistreatment
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Select all that apply
Subjected to offensive remarks or names related to race and/or ethnicity
Denied opportunities and/or received lower evaluations or grades because of race and/or ethnicity rather than performance
Other offensive behaviors related to race and/or ethnicity
Please select the type of sexual orienation based mistreatment
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Select all that apply
Subjected to offensive remarks or names related to sexual orientation
Denied opportunities and/or received lower evaluations or grades because of sexual orientation rather than performance
Other offensive behaviors related to sexual orientation
Please select the type of disability based mistreatment
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Select all that apply
Subjected to offensive remarks or names related to disability
Denied opportunities and/or received lower evaluations or grades because of disability rather than performance
Other offensive behaviors related to disability
Other: please describe the type of mistreatment
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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:
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6. What department does this person work in?
7. What is their role at UNM?
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Faculty member
Resident
Fellow
Post-doc
Administrator
Patient
Medical student
Graduate student
Other student
Nurse
Staff member
Other member of the care team
Other (please specify)
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?
Yes
No
Unsure
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:
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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
Ability to study
Anxiety
Depression
Other mental health issues
Burnout
Ability to sleep
Ability to take care of patients
Ability to work productively with the team
Self-esteem
Motivation
Trust
Sense of belonging at UNM
Sense of safety in the learning environment
Belief that UNM is a good place to learn and work
Other
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.
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