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Report of Possible Lapse in Professional Conduct

Please answer the questions below in order to submit your concern about a possible lapse in adhering to NYU Grossman School of Medicine's professional standards.

The response will be reviewed by the Office of Student Affairs (Associate Dean or designee).

All submissions are fully anonymous unless you wish to be share your name and/or wish to be contacted (the survey below asks for that info at the end).

Thank you for helping uphold our professional standards.

NYU Grossman School of Medicine ("NYUGSoM") students are valued members of the NYUGSoM and NYU Langone Health communities. From the start of medical school, like all members of the NYULH community, students are expected to uphold and manifest the highest standards of professional conduct and embrace values fundamental to our institution: performance, respect, integrity, diversity, and excellence.

The Professional Conduct Standards and Procedures strives to foster integrity and professionalism, both in the behavior of individuals and in the interactions among members of the medical community as a whole, and seeks to inform students who may encounter difficult moral and ethical issues when they arise throughout their medical career.

Our Professional Conduct Standards and Procedures promote expected behaviors and provide procedures for addressing lapses in professional behavior. It shall be the responsibility of the entire community to uphold the integrity and ethical standards set forth in Professional Conduct Standards and Procedures (the "Professional Conduct Standards").

This highly secure form (completely anonymous by default with an option of including your name/contact information ONLY if you wish to) provides a mechanism for any member of the NYUGSom/NYULH community to file a report of a suspected student violation of the Professional Conduct Standards.

The report will be reviewed by Associate Dean for Student Affairs who will then:

Alert the student named in the report within a week.
Investigate the report.
Determine how best to resolve the report, including both interim and/or informal and formal mechanisms and including the Council for Student Professional Conduct when indicated. Such mechanisms may include a range of sanctions as well as remediation and support services.

Full details are available in the Professional Conduct Standards and Procedures document.

The report of suspected violation of Professional Conduct Standards submitted via this form can be accessed only by the Associate Dean for Student Affairs (or designee) and the Division of Education Quality (responsible for maintaining the database or reports).

Copy of Professional Conduct Standards

Attachment:NYUGSOM Student Conduct Standards and Procedures approved 090524.pdf

Into which of the following categories of professional conduct standards does the suspected violation you wish to report fall?

(categories may be overlapping, so please select all that apply)

* must provide value

academic honesty and integrity

respect towards peers, faculty, and staff

cultural diversity, inclusion and health equity

positive learning environment

safe, effective, and respectful patient care

health and safety of the community

OTHER (please describe below)

Please describe the other category of professional conduct standards:

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What is your role at NYU Grossman School of Medicine?

* must provide value

Student

Faculty

Resident

Staff

Other

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If you selected "Other" to the above, please describe:

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What is the role of the person you suspect violated the Professional Conduct Standards?

* must provide value

If you selected "Other" to the above, please describe:

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Within which curricular stage did the incident occur? (Pre-Clerkship, Clerkship, etc.)

* must provide value

STAGE 1: Pre-Clerkship (Basic Science Modules and FCS)

STAGE 2: Clerkship (Core Clerkship Rotations)

STAGE 3 and BEYOND: Advanced Clerkships, Electives, and Other Programs

Other

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Please indicate in which specific Pre-Clerkship Curricular Unit or Activity/Program this incident occurred:

Foundations of Medicine (FOM)

Foundational Clinical Skills (FCS)

Organ Systems 1

Organ Systems 2

Organ Systems 3

Career Exploration Activities

Other

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Please indicate in which specific Core Clerkship this incident (these incidents) occurred:

Ambulatory Care Clerkship

Medicine Clerkship

Neurology Clerkship

Ob/Gyn Clerkship

Pediatrics Clerkship

Psychiatry Clerkship

Surgery Clerkship

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If the incident occurred in Stage 3 (post clerkship) or you chose other, please describe in detail:

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When did the incident(s) occur? Please provide a date.

If multiple incidents or occurred over a period of time, please enter the date for the first incident (or when the incident was first recognized/identified).

An estimated date is fine!

* must provide value

M-D-Y

Please provide a description of the incident:

* must provide value

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Please explain in detail how you think this incident (these incidents) could best be resolved:

* must provide value

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This form is TOTALLY ANONYMOUS (there is no way to link the response to an individual)!

However if you feel comfortable doing so, please provide your name and contact information below for follow up.

NAME (Optional):

KERBID (Optional):

EMAIL (Optional):

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.