Forms

• For Students
  Student Report of an Incident of Mistreatment, Unprofessional or Unethical Behavior
  Students are encouraged to report any mistreatment,, unprofessional or unethical behavior that they have experienced or witnessed during the preclinical or clinical years to the Associate Dean for Student Affairs. Students can submit an anonymous (or signed) report to the Office of Educational Affairs via the following online form:
  http://webcampus.med.drexel.edu/professionalism/IncidentReport.asp
  
  

  If you experience or witness mistreatment or unethical behavior and need to speak with someone urgently and confidentially, call the Student Affairs Emergency Hotline at 215-991-8184

  
  IFM Year 1 Small Group Peer Evaluation of Professionalism
  Use this FORM for the Peer Evaluation of Professionalism Program in Year 1. Use this link for general instructions and important information about the Peer Evaluation Program.
  
  
• For Faculty
  Commendation for Exemplary Professionalism
  All students are expected to demonstrate appropriate professional behavior, but there are instances of exemplary professionalism that should be singled out for recognition. A faculty member, staff member, or fellow student who directly observes such instances is encouraged to fill out a Report of Exemplary Professionalism. The faculty member, staff member or student is encouraged to discuss this form with the student and then forward the completed form to the Senior Associate Dean for Student Affairs. Students receiving Reports for Exemplary Professionalism will have this noted in their Medical Student Performance Evaluation (Dean's Letter).
  Download the Report of Exemplary Professionalism form (.pdf)
  
  Lapse or Deficiency in Professional Behavior
  Students who require assistance in developing professionalism skills should be identified and provided with opportunities to improve their skills and behaviors. Faculty, staff or students who identify students with deficiencies and/or areas needing improvement, are encouraged to submit a Report of Concern for Unprofessional Behavior. Reports of Concern for Unprofessional Behavior are NOT intended to replace one-on-one feedback. Rather, reports are intended for use in situations in which feedback has been unsuccessful and/or in instances in which behavior is grossly deficient.
  
  Levels of Concern: When submitting Reports of Concern for Unprofessional Behavior, the level of concern can be rated as "Moderate Level of Concern" or "High Level of Concern":
  • "Moderate Level of Concern" rating may be considered in response to behaviors that demonstrate a lapse or failure in professionalism that should be acknowledged, but one that does not jeopardize patient care, team performance, or academic progress. Examples include, but are not limited to: 1. Student does not submit assigned work by deadline 2. Student is late or absent for group activities 3. Student appearance or dress is not appropriate for setting or environment 4. Student does not participate in group/ team activities.
    
    
  • A "High Level of Concern" rating should be considered in response to lapses in behavior that require education, remediation and intervention due to significant lapses in: Integrity; Reliability and Responsibility; Self-Awareness; Team-Building and Communication; or Patient-Centered Care.

  Download the Report of Concern for Unprofessional Behavior form (.pdf)