Professionalism Form for Reporting on Faculty, Residents and Fellows

 

If your report deals with criminal behavior or serious allegations of sexual harassment that pose a threat to your personal safety, please contact the UCD police at 911; the non-emergency number is 303-724-4444.

 

This form allows you to provide the Faculty Professionalism Committee with a report on professionalism of a faculty member, resident or fellow. Professionalism is a cornerstone of medicine. It requires an ongoing commitment to honesty, integrity, respect, altruism, accountability, compassion, empathy and self-improvement. The University of Colorado School of Medicine affirms this commitment to students, residents and fellows, faculty and society.

 

Through EthicsPoint, students, residents and fellows have a process to confidentially report exemplary professional behavior OR lapses in professional behavior by faculty, residents and fellows. The reporter can also choose to remain anonymous. Reports will be reviewed and investigated in order to foster an environment of continuous professional behavior. For more information, please visit www.UCDenver.edu/professionalismfirst.

 

Items marked with a red diamond are required fields and must be completed before submitting the report.

 

 I witnessed:

 

 

Faculty Member, Resident or Fellow

Pre:

 First Name:

 Last Name:

 

 Position:

Department:

Your Name

Pre:

First Name:

Last Name:

Department:

 

The incident occurred in the following setting:

 
 

If Hospital, please specify where (i.e. inpatient ward, operating room, emergency department, other, etc.):

 
 

If Other, please specify:

 

 Did the incident involve caring for, or communicating with, patients or their families?

Did the incident involve any of the following?

Unmet professional responsibilities in the Teacher-Learner contract:

Speech or behaviors that create a hostile learning environment
Bias or prejudice toward learners
Lack of respect for diverse political, religious or cultural viewpoints or values
Negligent supervision or abandonment of learners
Learners treated unfairly or with favortism
Sexual harassment or violations of accepted boundaries
Other
 

If Other, please specify:

Did the incident involve any of the following?

Unmet professional responsibilites in clinical care settings:

Insensitivity to patients or their families
Bias or prejudice toward patients, nurses or other members of the health care team
Speech or behaviors that are humiliating, offensive or disrespectful toward patients, nurses or other members of the health care team
Failure to protect patient privacy or the privacy of health information
Sexual harassment or violations of accepted boundaries
Other
 

If Other, please specify:

Details
 
Submit
 
Submit – When you submit this report, you will be issued a Report Key (unique identifier for this report). Please print the page that is sent to you with the Report key. You will need this Report Key and the Password you choose below to provide additional information, to upload attachments, or to review, read or reply to the status of this disclosure, which you can do at any time after submitting this report. If you are making an anonymous report it is very important that you go back to the EthicsPoint site and use the Report Key to periodically check for messages from the Professionalism Committee as this is the only way that the Committee can communicate with you regarding the handling of your report. You can return to this EthicsPoint site and click on the “Follow up on a Report” link at the top of this page and enter your Report Key and Password to follow up on this report. You can also return to the ProfessionalismFirst web page and click on the “Follow Up on a Report” link to return to the EthicsPoint site.

 Password

 Re-Enter Password

(Passwords must be at least four(4) characters in length)
 
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