University of Pittsburgh
OMED-Professionalism or Mistreatment Incident Repo
Date of incident
Location of incident
Person of interest's role
Did you or anyone else do anything to mitigate or address the issue?
Please summarize the events below 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
The School of Medicine will protect confidentiality and respect anonymity should it be requested by you.
All reports will be handled, investigated and reported on a confidential basis by the professionalism panel such that reporter identity will be protected unless required by law or University policy.
Should you choose to submit this report anonymously, no identifiable information will be collected. Please note that anonymous reporting may hinder investigation and prevent follow-up. As a result, the School of Medicine recommends submitting your report in confidence.
Should you choose to submit this report confidentially, you will be asked to provide an email address. Your contact information will be used to provide a transparent process of investigation to you. We may contact you if we require additional information or after we have completed our investigation.
Please select how you wish to submit this information to us:
Click the Submit Form button below)
Confidentially (Please provide your contact information below)
Please provide us with your name:
Your role (i.e. student, resident, faculty):
Please check the box below.
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