Student Professionalism Lapse Report Student Professionalism Lapse Report Please note that the information contained in this report will be kept confidential. We cannot investigate anonymous reports. Professionalism lapses noted by a student, faculty member, house staff, patient, or other staff can be reported through this mechanism. Concerns about student mental health can be directed to Dr. Beverly Dede, Program Director, Student Counseling and Development at firstname.lastname@example.org. 1. Student Name2. Course/Clerkship/other site3. The following behaviors are considered to be unprofessional. Please check all that apply. Chronic tardiness/absence Failure to respond to emails in timely manner Inappropriate communications in person or media with patients Inappropriate communications in person or media with staff Inappropriate communications in person or media with faculty Inappropriate attire for setting Academic dishonesty Other-please describe in space below Please describe behavior from question 3 if other was selected.4. Please describe the incident that occurred-include as many details—date, time, names of involved parties—as possible.5. For faculty: Have you given the student feedback about the behavior? For staff or students: Have you alerted your supervisor about the behavior?6. Have you alerted the Course or Clerkship Director, if applicable, about the behavior?7. Please leave your contact information.