The UTRGV School of Medicine Professionalism Portal Faculty/Staff Reporting Form

Reporter's Information

Reports may be submitted anonymously. Only those areas that are marked with an asterisk are required to complete the form.

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Your full name:

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Your position/title:

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Faculty or Staff

Your phone number:

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Your email address:

Email address must be of a valid format.

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Nature of this report(Required):

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Urgency of this report(Required):

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Date of incident(Required):

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Time of incident:

Location of incident(Required):

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Specific location:

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Please provide additonal information: Will help us to route your form appropriately

Involved Parties

Please identify all parties associated with this complaint. To add the name of witnesses or others involved click the box below to add to this report.

Name or Organization

Select Gender

Select Role

ID Number

Questions

Supporting Documentation

Photos, video, email, and other supporting documents may be attached below. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Email me a copy of this report

Reporter's Information

Involved Parties

Questions

Supporting Documentation

Submission