Concern Information

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Concern Information

Date of concern *

YYYY

Report Source

For SMPH Student Mistreatment Triage Administration Use Only

Department of Concern

Academic Campus

Please indicate which campus location this incident occurred on (Madison, Milwaukee, Marshfield, La Crosse, etc.)

Location of concern

Please indicate which location this incident occurred on (UW Hospital, Marshfield, Aurora, Gundersen, etc.)

Concern description *

Please describe the concern with as much factual detail as possible. Please include information about the nature of the concern (e.g., physical assault, verbal assault, threats, written slurs, threatening communications, etc.), and please be as specific as possible. If you would prefer to share details of the concern in person, please provide the nature of the concern and select the option below to be contacted.

Involved parties

Please include name(s) and position(s).

Witnesses, if any

Mistreatment type *

Check all that apply (but at least one)

Belittling or humiliation

Discrimination on the basis of race, gender, sexual orientation, gender identity religion, ethnic background, age, or physical ability

Disregard for the safety of others

Insults or verbal attacks

Sexual harassment

Taking credit for another individual’s work

Threatening to assign a lower grade or to write a poor evaluation as a means of intimidation

Threats of physical harm or physical attacks

Other:

Required

Mistreatment concern targets:

Age

Disability

Race/ethnicity

Gender

Gender identity/expression

Marital status

National origin

Parental status

Political affiliation

Religion

Sexual orientation

Socioeconomic status

Veteran status

Other:

Other information considered to be relevant

This may include a desired outcome of this report, whether this concern has occurred before or whether this occurrence was reported elsewhere.

Are you willing to be contacted for more information regarding this report? *

Yes

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