Skip to Main Content
You are now in the main content area

Confidential Disclosure

*
(If disclosing as a group, please list all names)
*
(If disclosing as a group, please provide a primary contact person)
*
 I’d like to talk about what happened and what my options are
 I need academic accommodations or support
 I need personal support or a referral to counseling
 I’d like to understand possible reporting pathways (e.g., Human Rights Services)
 I need help with a safety plan or leave of absence
 I’m not sure yet. I just want to share this experience
 Other
*
 Yes
 No
 
*
 Yes
 No
*
(If more than 1 experience, please indicate date of most recent experience)
*
(If you're not sure, please write "unsure.")
*
(Specific individual(s), clinical team, learning environment, event, or situation)
*
*
(If you are disclosing on behalf of a learner, provide the learner’s program and year of study (if known).)
*
(If you are disclosing on behalf of a learner, what is the learner’s relationship to the person(s) involved? e.g., preceptor, resident, faculty member, peer, staff member, patient, etc.)
*
Please include as many details as you recall. When possible, present the information objectively. For example, in chronological order, using direct quotes, dates of multiple experiences, names of any witnesses, etc.
 
*
 Yes
 No
 
 
(Use this space to share anything else you feel is important about the experience.)

Disclosure Process

When you submit a confidential disclosure, a dedicated advisor from the Learner Affairs Unit will contact you within 72 hours. This first outreach is a check-in—an opportunity to understand what kind of support you may need. You’ll be able to talk through what next steps, if any, feel right for you. That could include personal support, academic considerations, or exploring a more formal process.

Nothing you share will be disclosed without your consent, unless there’s a serious safety concern.

We understand that learners have concerns around disclosing. The School of Medicine is committed to creating a confidential, supportive process for addressing concerns about mistreatment.

Retaliation of any kind—direct or indirect—against anyone who discloses mistreatment, shares information, or participates in a related process will not be tolerated and may result in disciplinary action.

For more information, please visit the School of Medicine’s Learner Mistreatment website.

Secure Record Keeping

Disclosures are stored securely and accessible only to the Learner Affairs Unit. All information is treated confidentially and used to provide support and maintain a positive learning environment.

Learner Affairs Unit

For more information about the Learner Affairs Unit and the supports available, please visit our website.

Note: Your form has not been submitted yet.

Please click “Submit” when ready.

*