Concern Wizard

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Professional Concerns Form

We value professionalism at the University of Alberta

The purpose of this professional concern 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 concerns 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 concern 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 concern reporting process, please click here.

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

For sexual violence crisis, options include:

For other forms of crisis including threats or violence, options include:

Concern Types

FoMD unprofessional behavior is not limited to, but may include:

  • Mistreatment (treats others badly, puts down others, yelling, insulting, belittling or offensive remarks)
  • Rudeness and Disrespect (lack of respect for others and others� opinions, foul language in the workplace)
  • Bullying, threatening and intimidation (use of superior strength/influence to force others to do what one wants)
  • Harassment (inappropriate physical and/or sexual contact, unacceptable behavior in the context of social norms)
  • Discrimination (unjust, unequal or prejudicial treatment of different categories of people based on grounds of race, ethnic origin, religion, marital or family status, genetic characteristics, age, gender identity, disability)
  • Spreading rumours, gossiping, says untrue things
  • Sexual or physical violence

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

Concern Reporting Form

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

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

You will be contacted by a triage officer within 3 business days of submission. Note: we are unable to respond to anonymously placed concerns due to not having the reporter�s contact information. We can only contact those who provide their names and contact information.

Date of Concern*
Location of Concern*
Setting of Concern
Course/Rotation
Person whom you are
reporting on:*
This person's role*

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

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

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

Confidentiality and Anonymity

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:*

Next Steps

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 concern 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.