Professionalism Form

It is expected that Carle Illinois College of Medicine faculty, staff, students, and representatives will conduct themselves at all times in accordance with University conduct, policies, and guidelines - including the Student Code, University Ethics, the Carle Standards of Conduct, and CIMED Professional Standards. The learning/work environment should be free of mistreatment, harassment, and threat of retaliation.

The following form can be used to report problematic or exemplary behavior. Please use the comments section to detail the behavior(s) or pattern of behavior(s) you are reporting.

Do not use this form to report events presenting an immediate threat. Reports submitted through this form will be reviewed within 2 business days. If there is an immediate risk to health or safety, please call 911 to connect with medical support or local law enforcement.

An individual may report an incident without disclosing their name, identifying the respondent, or requesting any action. Please note that choosing to make an anonymous report can significantly limit the ability of the college to respond. This information will be used for statistical purposes as well as for enhancing understanding of our college climate so that we may strengthen misconduct response and prevention efforts.

Your Full Name (optional)

Your Email Address (optional)

Date(s) of Professionalism Incident

Reporting Compliment of Professionalism/Concern of Professionalism

Name of Respondent

Role of Respondent

More than one category may apply (to select multiple items in a drop down list, press Ctrl+click).
Please use the comments section to detail the behavior or pattern of behavior you are reporting.

Professional Ethic

Recognize his/her/their biases and not allow them to affect patient care or contribute to threatening or harassing interactions with others

Demonstrate an awareness of costs and resources, quality of life, and related ethical decisions

Demonstrate respect for the life, health, or the autonomy of the patient

Uses illicit substances OR uses alcohol, non-prescription drugs or prescription drugs in a manner that compromises ability to contribute to patient care or the safety of others

Misrepresents self, others, or members of the team to others

Professional Relationships & Responsibilities

Demonstrates compassion and respect for others

Vigilant in regard to personal conflicts of interest, such as acting in ways designed to advance one’s own career, family and allies’ interests, finances, power or influence when contrary to the best interests of the patient

Demonstrates empathy and respect for all faculty members, students, residents, staff and patients and their families without regard to any intrinsic or extrinsic personal behaviors, characteristics, or beliefs

Recognizes and admits mistakes; seeks and accepts feedback and uses it to improve performance

Maintains professional composure and exhibits good personal and clinical judgment in stressful situations

Recognizes the importance of maintaining professional behavior in the clinical setting in spite of inappropriate action on the part of others

Displays appropriate professional appearance and is appropriately groomed

Reliability and Responsibility

Maintains data secuirty, student information protected by FERPA, and patient confidentiality

Maintains integrity of assessments and instructional materials; does not share PBL cases

Observes academic honesty in all circumstances and is trustworthy

Acts independently to identify and complete tasks as they arise

Arrives on time and actively participates in teaching/learning opportunities

Follows through with clinical responsibilities; is reliable and conscientious

Professionalism: Reliability and Responsibility

Responds to communications (e-mail, pages, phone calls, e-mails, etc.) in a timely and professional manner

Patient, Faculty, Resident, Administrative Staff, and Other Team Member Interactions

Professionalism: Patient, Faculty, Resident, Administrative Staff, and Other Team Member Interactions

Manages conflicts with tact and discretion

Works effectively as a member of a team or organization to promote interpersonal, professional, and society development

Communicates honestly, directly, and tactfully with patients, families, peers, faculty, staff, and students in all situations and interactions

Contributes to or fosters a positive learning environment

Patient, Faculty, Resident, Administrative Staff, and Other Team Member Interactions

Describe the behavior reported, describe the impact to yourself/others,
and describe the environment in which this behavior took place.

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