JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Doctor sex abuse and misconduct
We will not use your name without your permission; You may submit anonymously but we would prefer your name.
Sign in to Google
to save your progress.
Learn more
Name
Your answer
City and State
Your answer
Tell us about yourself
Patient
Doctor
Nurse or other medical personnel
Medical board or disciplinary board member
Other:
Clear selection
Patient's name if you are not patient (can leave anonymous)
Your answer
Doctor's name (can leave anonymous)
Your answer
Tell us about your experience
Your answer
Was this reported to any medical board or official body?
Yes
No
Clear selection
Was this reported to police?
Yes
No
Clear selection
Does this experience still affect you today?
Yes
No
Clear selection
Can we use your name in a news article?
Yes
Maybe, please contact me first
No
Other:
Clear selection
Your email
Your answer
Best phone to reach you
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
Forms
This content is neither created nor endorsed by Google.
Report Abuse
Terms of Service
Privacy Policy
Help and feedback
Contact form owner
Help Forms improve
Report