Mistreatment Reporting Form

* - required field

Mistreatment Information
1.

* I have read the definition of mistreatment posted on the "Information for Students" website

2.

* Having read the definition of student mistreatment, I believe that I suffered mistreatment as a student that was outside the bounds of acceptable behavior.

* Please describe the behavior or incident

3.

* Please choose the best descriptor of the inappropriate behavior (choose all that apply).

 

Please Specify:

4.

* The individual I hold responsible for this behavior is:

 

Please Specify:

5.

The name of the individual you are complaining about is: (optional)

6. Rotation or elective (optional)
7. Rotation or elective site (optional)
8. Pre-clinical Course (optional)
9. * Your Name
10. * Your Email Address: Please enter an Einstein med email address username@med.einstein.yu.edu