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University of Illinois Urbana-Champaign
University of Illinois at Urbana-Champaign
Carle Illinois College of Medicine
Professionalism Form
THE LEARNING/WORK ENVIRONMENT SHOULD BE FREE OF MISTREATMENT, HARASSMENT, AND THREAT OF RETALIATION.
PROFESSIONALISM CONCERNS AND COMPLIMENTS NOT REGARDING CI MED STUDENTS
This form is for submitting professionalism concerns and compliments regarding
CI MED students
. All other professionalism concerns and compliments should be submitted to the sources below:
Concerns regarding
CI MED staff
should be directed to the
Chief of Staff,
Dr. Rosalind Garcia-Tosi
.
Concerns regarding
CI MED faculty
(both clinical and non-clinical) should be directed to the
Office of Faculty Affairs and Development,
Dr. Deb Young
.
Concerns regarding
CI MED clinical non-faculty
should be addressed through the
Office of the Learning Environment,
Dr. Mark Shima
.
DEFINITION OF PROFESSIONALISM
Professional behavior is referenced in the work of the AAMC, including Patient-Centered care, Ethical conduct, Competence and skill, Accountability and Responsibility, Communication and Interpersonal skills, Continuous learning, Altruism, and Professional readiness. Additional information on CI-MED Student Professionalism can be found in
APS-4
in the student handbook.
EXPECTATIONS
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
CI MED Professional Standards
.
IN CASE OF IMMEDIATE RISK
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.
ANONYMOUS REPORTING
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.
Mistreatment or Professionalism
Mistreatment or Professionalism
Mistreatment
Professionalism
Submission Date
THE FOLLOWING FORM CAN BE USED TO REPORT PROBLEMATIC OR EXEMPLARY BEHAVIOR
Your Full Name (optional)
Your Email Address (optional)
Date(s) of Incident
Behavior(s) Reported Below
Behavior(s) Reported Below
Mistreatment (Personally Experienced)
Mistreatment (Witnessed)
Duty Hours Violation
Unsafe Environment
Inappropriate Clinical Expectations
Concern
Compliments
Name of Respondent
Primary Role of Respondent
Student
Staff
Faculty
Professional Ethic
(Select all that apply)
Professional Ethic
(Select all that apply)
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 and Responsibilities
(Select all that apply)
Professional Relationships and Responsibilities
(Select all that apply)
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
(Select all that apply)
Reliability and Responsibility
(Select all that apply)
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
(Select all that apply)
Patient, Faculty, Resident, Administrative Staff, and Other Team Member Interactions
(Select all that apply)
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(s) or pattern of behavior(s) you are reporting, the impact to yourself/others, and describe the environment in which the behavior(s) took place.
Related Attachment
This form will be sent to the Associate and Assistant Deans for Student Affairs. If that presents a conflict of interest, please contact the Executive Vice Dean of Carle Illinois College of Medicine.
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NOTE: Only applications submitted through AMCAS will be accepted and reviewed.