Agenda and Meeting Materials - UConn School of Medicine ...

APPENDIX E:
University of Connecticut School of Medicine
Professionalism Incident Report
Type of Report (circle one) PRAISE CONCERN
Subject of Report (Student Name): Date of Report:
Person Submitting Form Date/Time of Incident
(include title and/or role): (time period if longitudinal observations):
Action Requested (circle one) For File Only Referral to Professional Incident Report Triage (PIRT)
I. Statement summarizing the behavior being praised or raising concern:
II. Describe in detail the incident(s) which prompted the completion of this form (attach additional
pages if needed).
III. Describe previous feedback and remediation which took place prior to the completion of this form
(attach additional pages if needed) if applicable.
IV. Summary of attempts to resolve this current issue and report of outcome, if any.
[NOTE: The following to be completed by a Member of Professionalism Incident Report Committee]
Student Subject of report:
I have read this description and discussed it with the individual who filed the report, and/or a representative of the
Professionalism Committee.
Signature: ____________________________________ Date: ___________________
Student signature on this form is intended only to verify that the student has reviewed the form with the individual
who filed the report, and/or a representative of the Professionalism Committee.
Student Comments:
Professionalism Incident Report Committee Member:
I have reviewed this evaluation.
Signature: ____________________________________ Date: ___________________
PIRT Member Comments: