Student Mistreatment Report

1. I am reporting this incident on behalf of:

Myself
A fellow student

2. The incident happened to:

Me
A fellow student

3. 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.

3A. 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 #4

4. 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 below

5. 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 location

8. The name of the person who committed the alleged behavior

9. 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 (Associate Dean of Student Affairs)
Dr. Genuardi (Associate Dean of Student Affairs - Jacksonville Campus)
Dr. Harrell (Associate Dean of Medical Education)
Dr. Madani Sims (Assistant Dean of Student Affairs)
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.

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