Student Mistreatment Report Student Mistreatment Report This report is confidential and while it can be filed anonymously, students are encouraged to provide contact information so the incident can be more fully reviewed. The College of Medicine is required to report incidents incongruent of Title IX guidelines to the University Title IX office. Behaviors listed below committed by a faculty member, house staff, patient, other student, or other staff can be reported through this mechanism. 1. I am reporting this incident on behalf of:MyselfA fellow student2. The incident happened to:MeA fellow student3. The following behaviors are considered to be unprofessional and may constitute student mistreatment. Please select all that apply by holding the control (Ctrl) key while clicking.Public HumiliationThreatened with physical harmRequired to perform personal services (e.g. babysit, pick up dry cleaning)Received lower evaluations/grades not because of performance, but because of gender or sexual orientationReceived lower evaluations/grades not because of performance, but because of race or ethnicityReceived lower evaluations/grades not because of performance, but because of religious beliefs/practicesDenied an opportunity or opportunities for training or rewards based on gender or sexual orientationDenied an opportunity or opportunities for training or rewards based on race or ethnicityDenied an opportunity or opportunities for training or rewards based on religious beliefs/practicesSubjected to offensive remarks or names related to gender or sexual orientationSubjected to offensive remarks or names related to race or ethnicitySubjected to offensive remarks or names related to religious beliefs/practicesMacro/micro aggressions and witnessed biasOther, please see next question3A. Please list any other behaviors considered to be unprofessional related to student mistreatment.i. *Please note that based on the facts involved, some incidents may fall under Title IX and will require investigation as indicated below in #44. The following behaviors are unprofessional and constitute mistreatment. They are also are subject to Title IX reporting. Please check all that apply. Subjected to unwelcome physical conduct of a sexual nature Subjected to unwelcome requests for sexual favors Subjected to unwelcome verbal conduct of a sexual nature that is made in an implicit or explicit term or condition of education Asked to exchange sexual favors or dates for grades or other rewards Other, please see box below • Please note: All Title IX investigations are confidential. Students are encouraged to provide contact information so the incident can be fully investigated. The university has a responsibility and an obligation to fully investigate this type of incident, counsel the impacted student and provide options for next steps. The University Title IX Process can be found in this link: https://titleix.ufl.edu/wp-content/uploads/2018/02/10-17-University-of-Florida-Title-IX-Process-1.pdf. The Title IX website can be found at https://titleix.ufl.edu/Please enter other below5. Please describe the incident that occurred-include as many details—date, time, names of involved parties—as possible.6. This event occurred in association with which of the following? Pre-Clerkship Course Clinical Clerkship MSRP: Research Mentor Preceptorship: Clinical Mentor Other 7. Please provide as much detail as possible on the course/clerkship name and location8. The name of the person who committed the alleged behavior9. Please select from the following list when you want a review of the event to begin. Please note that in situations where the safety of a student is at risk, the investigation will begin immediately. Additionally, in situations where a Title IX infraction may have occurred, the Title IX office must be notified right away, but the student still has the option to delay any interventions. I want the event reviewed as soon as possible I want the event documented now, but reviewed after the grade for my current clerkship/course is finalized I want the event reviewed at the end of this academic year I do not want the event reviewed, I just want it documented (may not be possible for egregious behaviors, Title IX behaviors, or situations where student safety may be at risk) 10. I would like the following to initiate the review of this incident. (please select two) Dr. Collins (Assistant Dean of Medical Education) Dr. Duff (Associate Dean of Student Affairs) Dr. Genuardi (Associate Dean of Student Affairs - Jacksonville Campus) Dr. Harrell (Associate Dean of Medical Education) Dr. Jacobs (Assistant Dean for Office of Diversity and Health Equity) Dr. Parker (Associate Dean for Office of Diversity and Health Equity) 11. If you are willing to speak directly to the dean who will review this matter, please leave your contact information.