Student Mistreatment Report Form

Anonymous Reporting: Individuals may report an incident using this form without disclosing identifying information (i.e., name, email and phone number fields are optional) or requesting any action. Reports submitted in an anonymous manner may, however, significantly limit the ability of the College to investigate and address the incident. However, all reports will be reviewed and a reasonable effort will be made to address the incident. In addition, anonymous reports will be helpful in identifying any patterns or trends of mistreatment that may be occurring in a particular department, unit or site, which will also enhance our understanding of our college climate so that we may strengthen misconduct/mistreatment response and prevention efforts.

Reporting Party Contact Information

If you wish to submit a report anonymously, meaning your name is hidden when your report is submitted, you should not include any identifying information with your submission, such as adding your name, phone number, and/or email address or using your name in the description of the incident(s). If you provide identifying information when submitting this report, you will not submit the report anonymously and a designated person at your campus may follow up with you to discuss your report.
  • * Were you the recipient of mistreatment or a witness to mistreatment?
  • * At which campus (or one of its affiliated training sites) did the incident(s) occur?

Urbana - For incidents that involve Urbana students, reports should be made through the COM Urbana site: here

Information about whom complaint is being made (referred to here as the respondent).

  • * Who mistreated you or another? (check all that apply)

Other Information

  • Do you request that a designated individual at the University of Illinois College of Medicine follow up with you to discuss this report?

Information About The Incident(s)

Please provide as much detail as possible regarding the incident/concern using specific, concise, and objective language (Who, what, where, when, why, and how).

Optional Additional Information

  • Do any of the options below indicate the way(s) you perceive that you or another were mistreated? (check all that apply)
  • Do you believe the mistreatment may be related to any of the following categories? (check all that apply) – if so , you should also contact the UIC Office for Access and Equity
If you would prefer not to complete this form or you have any questions related to the form or the process, we encourage you to contact the UI COM Director of Medical Student Learning Environment (DMSLE) at (312) 413-9632 or timlacy@uic.edu, regarding options for next steps.
Thank you for submitting a report of mistreatment. Notification of your submission will be sent and the report will be reviewed within 2 business days following that notice. If you would like to follow up on this report, please contact the Director of Medical Student Learning Environment (DMSLE) at (312) 413-9632 or timlacy@uic.edu