Mistreatment Reporting Form

* - required field

Mistreatment Information
1.	* I have read the definition of mistreatment posted on the "Information for Students" website Yes No
2.	* Having read the definition of student mistreatment, I believe that I suffered mistreatment as a student that was outside the bounds of acceptable behavior. Yes No Not certain that it was out of the bounds * Please describe the behavior or incident **disclaimer - all instances that fall under Title IX will go through those channels
3.	* Please choose the best descriptor of the inappropriate behavior (choose all that apply). Publicly belittled or humiliated me Threat of harm or being physically abused Asked to perform services unrelated to education or patient care (shopping, etc.) Threat of grading or other form of assessment as a reward or punishment for inappropriate requests Other Please Specify: *Note:* Any discriminatory behavior or sexual mistreatment or misconduct must be reported pursuant to Einstein’s Non-Discrimination and Gender-Based Misconduct Policy and Complaint Procedures for Students (which must be reported pursuant to that policy).
4.	* The individual I hold responsible for this behavior is: Attending/Faculty Resident/Fellow Preceptor Allied Health Care Worker (Nurse, P.A., Social Worker, Clerk) Site Leader Course Director Student Other Please Specify:
5.	The name of the individual you are complaining about is: (optional)
6.	Rotation or elective (optional)
7.	Rotation or elective site (optional)
8.	Pre-clinical Course (optional)
9.	* Your Name
10.	* Your Email Address:	Please enter an Einstein med email address username@med.einstein.yu.edu or username@mail.einstein.yu.edu