Incident Wizard

We value professionalism at the University of Alberta

The purpose of this professional incident form is to enable a confidential reporting mechanism for learners and staff to identify any mistreatment or unprofessional conduct they have experienced within any of the learning environments of the Faculty of Medicine & Dentistry.

This form should be used for reporting incidents only and should not be used for emergencies.

All forms will be reviewed within 72 hours of submission, and will be triaged according to level of urgency.

All individuals who submit a professionalism incident form will receive a summary of the conclusion of the process,
should they choose to provide their contact information.

For a full review of the incident reporting process, please click here.

Is this a concern about a medical student?*

Have you experienced or witnessed an event that involves immediate health or safety concerns?

Please seek medical assistance, if appropriate.
Please contact police/ academy security, if appropriate.
When you are able to, please return to this form and complete it, so that we may address your concerns.

Student Mistreatment is not limited to, but may include:

  • Public belittlement or humiliation
  • Being threatened with physical harm
  • Required to perform physical services such as shopping or babysitting
  • Asked to exchange sexual favors for grades or other awards
  • Denied opportunities for training due to race, ethnicity, gender or sexual orientation
  • Subjected to racially, ethnically or sexually offensive remarks
  • Received lower evaluation or grades solely because of your race, ethnicity, or gender

This form should also be used to report any other major unprofessional behaviours occurring within the student learning community. Such incidents may be detrimental to the learning environment due to either severity or repetition, and may include:

  • Speaking rudely
  • Using foul language in the workplace
  • Not respecting the opinions or expertise of team members
  • Showing up late for duty without reasonable cause

Do you feel the events in this incident meet the definition of student mistreatment?

This form should be used for reporting incidents only and should not be used for emergencies.

All forms will be reviewed within 72 hours of submission, and will be triaged according to level of urgency.

All individuals who submit a professionalism incident form will receive a summary of the conclusion of the process, should they choose to provide their contact information.

Date of Incident*
Location of Incident*

Course/Rotation
Person of Interest's role*

Person's name:*
Please summarize the events of the incident including details such as:
  • Nature of the incident
  • Names of all those individuals involved EXCEPT PATIENTS
  • Precise time and location
  • Whether you experienced the incident yourself or witnessed someone else experiencing it

Please note: The events of the incident must be made in good faith and to your best recollection of the incident. Filing of a false, frivolous, vexatious, or malicious report will be considered a professionalism lapse.

Incident description:*
Did you or anyone else do anything to mitigate or address the issue?*
Please describe:*

The FoMD 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 any follow-up reporting mechanisms. As a result, the FoMD would like to recommend submitting your report in confidence to the FoMD program.

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. You will also receive further contact should we require more information or have completed our investigation.

For a description of this reporting mechanism, please click here.

Thank you for your confidence. Please provide your name and email for further confidential contact.

Please provide us with your name:*
Please provide your email:*
Please provide us with your role:*

Thank you for your submission. A notification has been sent to the designated professionalism committee member notifying them of your submission. Your report will be reviewed within 72 hours of submission. However, investigation and resolution of the incident will require more time. If you have provided your contact information, you will receive a final report of the resolution of the investigation.

If you have not received a response within 3 business days, please email fomdprof@ualberta.ca.