Report of mistreatment

Your identity is not attached to this reporting form, but there is an option to identify yourself below if desired. You may complete reports as many times as you would like. These reports go to the Associate Dean for Student Affairs (ADSA) and are then fully de-identified and reviewed by the Committee on Respectful Learning Environment—CRLE (the ADSA, a pre-clinical faculty member, the student government VP for diversity, a nurse manager and a clinical psychologist). You are encouraged to contact your coach, the course/clerkship director, an advocate for students, any of the associate deans (Preclinical, Clinical, Diversity and Inclusion) or the DICE office if you are unsure if an instance constitutes mistreatment and want to first further discuss before submitting. What is mistreatment?

Entries marked with * are required.

Have you experienced mistreatment from a faculty member, resident, fellow, fellow student or staff member in general or on a course or rotation?*:
Have you witnessed mistreatment from a faculty member, resident, fellow, fellow student or staff member in general or on a course or rotation?*:
Have you experienced or witnessed mistreatment from a patient or patient support person in general or on a course or rotation?*:
Please check the role of the party engaged in the mistreatment*:
Course*:	(ex. On Doctoring, pediatric clerkship, surgical oncology subi)
Location*:	(ex. DHMC, VA, CPMC, DH-Nashua)


In reporting mistreatment from patients and families, please note if the clinical team was aware of the incident and did or did not engage in supportive actions. Acknowledgement will be given to team members who took supportive action and skills training will be provided to team members who did not, so they may improve.
This system is a safe space to tell a story. A statement of the facts provides the CRLE with the information needed to make a determination about whether mistreatment occurred and if so, to be able to provide more specific feedback to those involved. Interpretation of events are harder to review.
Please describe what happened*:	Example of a story: "Dr. X said that if I became a neurosurgeon, no one would ever marry me." Example of an interpretation: "Dr. X made sexist comments that interfered with my ability to perform well."

First time reports Geisel's approach to first time reports on individuals cited for mistreatment is through a "feedback talk" with a trained facilitator who is not in an authority position over the named party. The specifics of the situation are adjusted such that the reporting student and the timing of the incident are not identifiable. The course director and department chair or residency program director or other appropriate supervisor are alerted but do not become involved in the feedback process, and the student is not identified to the chair or course or program director.
Egregious Reports If an instance of mistreatment is deemed to be egregious (i.e. it would be potentially dangerous to have another student work with the named party) or falls under Title IX (sexual harassment) immediate action may have to be taken to protect the health and safety of community members. This takes a separate pathway involving supervisors and the potential of disciplinary action and students may not control this timeline.
Multiple Reports of One Individual If an individual is named more than once (over a time period of years) the individual's supervisor is notified and engaged in the feedback process. After three or more reports or any egregious reports, supervisory and/or disciplinary action occurs.

Is the "feedback talk" approach acceptable in this reported instance?*:

What alternative outcome would you like to see after this reporting?:

When would it be acceptable to have a "feedback talk", or to notify the individual's supervisor, or to pursue the alternative approach that you proposed?*:

Other:

How who you like to be notified about the outcome of this reporting?*:

I would like to hear back from the ADSA directly
I prefer to hear feedback through my coach/DICE/the course director/other advisor
I prefer a fully anonymous report and will not receive any feedback except through de-identified aggregate feedback to all students

Your Name:

Surrogate Name:

To receive this feedback, please speak with the person here identified and let them know you submitted a report. The ADSA will inform him/her of the outcome and they will get back to you.

What else would you like to share about this report? You are welcome to share anything here. This includes but is not limited to how this event affected you, what you wished occurred, how it might have been prevented, or how we can improve our learning environments. Please note here if this instance was already reported elsewhere as well, such as through the DICE reporting mechanism or to a course director or other party.

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