DEM Equity Check-In form
In order to strive towards our goal of the most equitable and inclusive workplace possible, this form has been created as an anonymous means of reporting threats to that environment. This form is meant to give residents and faculty the opportunity to celebrate excellence, share concerns about education and patient-care, and report any incidents or behavior that do not align with our mission to have a safe and inclusive learning and patient-care environment. This includes concerns that anyone may have with regards to race, gender, and sexual orientation. If you encounter (personally or witnessed) microaggressions, implicit bias, sexual harassment, or ANY act of exclusion (even with regards to patients) this survey is here to provide you with a safe space to draw attention to the issue.

Events or issues reported via this form will be reviewed by the DEM Director of DEI (Dr Mariana Martinez). Themes will be collected to inform educational interventions for faculty, staff or residents as appropriate. Recurring issues with any individual will be taken to the appropriate authority (departmental, nursing or resident leadership) for review. Feel free to remain anonymous in your reports. However, any concerns reported using this form regarding resident safety, including sexual assault, violence, or other sensitive manners will be reported to the SAFE committee according to DHS policy. The SAFE committee will review and investigate and mobilize the appropriate resources and determine if an additional investigation is needed and how to conduct it.

Further resources:
DEM Director of Diversity, Equity and Inclusion, Dr Martinez, dem.dei@med.usc.edu
GME SAFE Committee (A committee centered on resident safety, fairness, & equity)
Dr. Opas - Designated Institutional Official (Lawrence.opas@med.usc.edu)
Dr. Chambers - Assistant Designated Institutional Official (tamara.chambers@med.usc.edu)
24 hour hotline (323.409.LINE)
Human Resources (323.409.2300)
The LAGMC Safety Intelligence System (safetyintelligence.lacounty.gov/DHS)
USC Office of Professionalism & Ethics (report.USC.edu or 800.348.7454)
ACGME Office of Resident Affairs (acgme.org/Resident-and-Fellows/Report-an-issue)  

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Name, PGY year (if you prefer to remain anonymous, type anonymous) *
Excellence in creating an equitable learning environment
If there are any residents, faculty, staff, or student you would like to celebrate for their excellence, please describe here.
Concerns regarding education and/or patient-care
If you witnessed any incidences in which education and/or patient-care was compromised, please describe below. This is a safe space to voices these concerns. 
Other Issue/Concern/Incident you wish to mention
This is a safe place to bring to light an incident or issue you would like addressed. Your safety and wellness is of the utmost importance, so if an issue is shared that puts into question your well being, then the SAFE committee may be contacted to determine the best way to resolve the situation.
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