ASA: Student Mistreatment Incident Report Form

Student Mistreatment Incident Report Form

This Student Mistreatment Incident Report Form is designed for students to report any incidences of mistreatment or unprofessional conduct they may have experiences within any of the learning environments of UNR Med.

Examples of mistreatment may include the following and further information can be found in the Student Mistreatment Policy

Yelling at and/or verbally berating a student in public or private
Actions reasonably interpreted as demeaning or humiliating in public or private
Assigning duties as a means of punishing students instead of for educational benefits
Unwarranted exclusion from learning opportunities
Threats to fail, assign a lower grade or give a poor evaluation for non-academic reasons
Requesting that students complete personal chores or errands
Unwelcome or inappropriate comments or discrimination related to a student's physical appearance, age, gender, race, ethnicity or culture, sexual orientation, sexual identity, disability or marital status
Pushing, shoving, slapping, hitting, tripping, throwing objects or other forms of physical intimidation
Sexual harassment per the NSHE Administrative Code, Title 4, Chapter 8, Section 13, Subsection B

Assurances Against Adverse Effects of Grades and Retaliation

Please know that by filling out this form your grade will not be affected and you will be protected from any of type of retaliation or backlash from the person(s) of interest. Retaliation against students reporting mistreatment is regarded as a form of mistreatment, will not be tolerated and will be handled in the same manner as accusations concerning other forms of mistreatment. Dishonest or malicious accusations will also be subject to disciplinary action.

Date of incident/Date of first incident*

Is this a recurrent incident*

Yes No

Location of incident

Person of interest's role*

Other:*

Please describe

Person's name

Did you or anyone else do anything to mitigate or address the issue?*

Yes No

Do you feel safe in that environment?*

Yes No

This form is not for reporting emergencies and should only be used for incident reporting. In an emergency, please contact your attending physician, clerkship director or Dr. Singer. If you do not feel safe, please dial 911.

Details*

Please summarize the events including details such as, the nature of the incident, names of all the individuals involved (except patient names), precise time and location, whether you experienced the incident yourself or witnessed someone else experiencing it.

Confidentiality and Anonymity

UNR Med will respect the confidentiality of those submitting reports. Information will be reviewed and investigated to provide for a prompt evaluation of the incident.All reports will be reviewed by the Associate Dean of Student Affairs to determine the course of action need to ensure a professional and optimal learning environment.

Submitting Anonymously: Your contact information will not be collected. The information will be collected for reporting purposes but and no further action will be taken unless details can be substantiated.
Submitting Confidentially: You will need to provide your name and contact information and may be contacted during the investigation should more details be required. Please note that all reports of sexual harassment required mandatory reporting by UNR Med to the UNR Title IX Office.

Please select how you wish to submit this information to us:*

Anonymously Confidentially

First Name*

Last Name*

Your Role*

Student, Resident, etc.

Email*

Thank you for taking the time to submit this form; your feedback will help us ensure a comfortable and supportive learning environment at UNR Med.

Please feel free to contact Dr. Singer (csinger@med.unr.edu) or Dr. Calvo (lcalvo@med.unr.edu) directly if you would like to meet to further discuss this or any other issues that you may have.

As a reminder, UNR offers confidential counseling services free of charge to all medical students at UNR Counseling Services. They are located in the Pennington Student Achievement Center. Same day appointments can be made by calling (775) 784-4648.