Reported to

If you have already reported the situation or incident to another office or individual, please provide us with their name and contact information. This will facilitate coordination.







Reporter
I am or was involved in the situation or incident.
I witnessed the situation or incident.
This means you saw the situation or incident but were not involved in it.
Other

Status *

The context of the situation or incident is a very important element. Please indicate your status in order to provide us with some context.

I am a/an:




Yes   No

Reporter Information

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It is important to note that with an anonymous report, the respondent would be notified under most circumstances. Depending on the nature of the report and any other collaborating reports, there may be limitations to the interventions the Faculty of Medicine is able to carry out. The Faculty of Medicine is committed to Professionalism and its principles; sometimes due to the limiations of an anonymous report, only limited responses may result.
Respondent

The subject of the report.

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Status *

If you don’t know the respondent’s status, please include as much information as possible in the free form comments section.


Incident

Type *

Location *


Dates

The start date refers to when you first witnessed or were involved in the situation. If it is ongoing, then do not enter an end date.

*

Details *


Witness