Honor Code Reporting Form

Request edit access

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Thank you for taking the time to fill out this Honor Code Violation Reporting Form. All information provided is shared with the Honor Committee Student Chair, Honor Committee Student Advisors and Faculty Advisors.

Please keep in mind that this process is otherwise confidential. Documents and information obtained will only be used in connection with the Honor Committee process and for no other purpose.
Please provide a detailed description of the incident/concern using concise, objective language. Please be as specific as possible as you include all relevant information, including who was involved in the incident, how each person associated with this report was involved in the incident, what happened during the incident, where the incident took place, and when the incident took place.

Access to the USCSOM Columbia honor code can be found at https://www.sc.edu/study/colleges_schools/medicine/internal/documents/student_docs/md_policies_and_forms/uscsom_honor_code.pdf.

Only the Student Chairs, MIV Advisor, and Faculty and Staff Advisors of the Honor Committee will know your identity.

If you have any questions regarding this form, please email honorcommittee@uscmed.sc.edu.

Email *

Your full name *

Your position *

Date of incident *

YYYY

Time of incident *

Time

Where did the incident occur? (Please specify which SOM campus. If off campus, please include an address.) *

Full name of the accused student(s) *

Full name of other witnesses (if applicable)

Program(s) of the accused student(s) involved *

Physician assistant

Nurse anesthesia

Genetic counseling

Biomedical sciences (PhD/Masters/Certificate)

Rehabilitation counseling

Required

Was this incident reported to law enforcement? *

Yes

Unsure

Was this incident reported to an agency outside of the University? *

Yes

Unsure

Below are categories that correspond to the Honor Code. Please indicate the relevant sections that pertain to this incident report. *

Giving/receiving unauthorized aid

Plagiarism

Bribery

Inappropriate file sharing

Failure to report suspected Honor Code violation

Cheating

Discrimination

Inappropriate relationships with patients or their family members

Violation of patient privacy

Intoxication on duty

Disrespect and non-cooperative behavior toward peers, faculty, and staff

Intentional misrepresentation by word or action (i.e. lying)

Failure to complete equitable portion of clinical or preclinical workload

Inaccessibility while on duty

Unexcused absence from mandatory class or clerkship

Repeated tardiness at required events (classes/rotations)

Unprofessional appearance, attire or personal hygiene

Untimely completion of preclinical/clinical work (clerkship evaluations/patient charting)

Other:

Required

Please provide a detailed description of the incident/concern using specific concise, objective language. Please make sure to include all relevant information, including who was involved in the incident, how each person associated with this report was involved in the incident, what happened during the incident, where the incident took place, and when the incident took place. *

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Forms