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


Yes   No

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:


Reporter Information

*
*
*


*
*
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.

*
*
*

Status *

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


Incident

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 *

Type *


Witness




Reported to

If you have already reported the situation or incident to another office or individual, do not submit a second report. Please indicate, however, the name of the other office or individual to facilitate coordination between different offices or organizations for follow-up.