University of Pittsburgh
OMED-Professionalism Accolades Report Form
Date of occurrence
Location of occurrence
Person of interest's role
Please summarize the events, including details such as:
• the nature of the behavior;
• names of all the individuals involved (except patient names);
• time and location (if applicable);
• whether you experienced the occurrence/behavior yourself or witnessed someone else experiencing it.
Confidentiality and Anonymity
The SOM will protect confidentiality and respect anonymity, should it be requested by you.
All Professionalism Accolades reporting forms will be handled and reported in a confidential manner 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 follow-up. As a result, we would like to recommend submitting your report in confidence.
**Should you choose to submit this report confidentially, you are asked to provide an email address. We may contact you if we require additional information.
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
Please provide us with your email address
Please provide us with your role (i.e. student, resident, faculty)
Please check the box below.
Do Not Fill This Out