Professionalism Notification Form

Student Name______Date______

Person submitting notification: Name______Signature______

Course______Course Director______N/A______

Course Director signature______N/A______

Professionalism concern is in the area of: Circle all appropriate categories. Comments are required with specific incidents. Please add additional pages as required. If the behavior raising a concern rises to the level of a potential Honor Code violation, please follow the procedure for reporting Honor Code violations found in the Bulletin of the School of Medicine.

1. Commitment to Learning a. often appears passive or disinterested b. has to be encouraged or reminded to engage in required learning opportunities c. disregards or rejects feedback or opportunities for improvement

2. Respect for Others a. disrespectful of others as evidenced by rudeness, hostile or inappropriately critical remarks, using derogatory terms or labels b. repeated lack of punctuality c. inappropriate dress or overly casual language or demeanor d. “gunning”, attempts to disadvantage other learners through competitive behavior

3. Honesty and Integrity a. dishonest about or misrepresents knowledge, sources, attendance, or role in care b. unable to acknowledge errors or deficiencies c. does not follow through with commitments; not trusted by team

4. Conscientiousness a. does not complete reports, assignments, and exams on time or make appropriate requests for extensions b. does not request excused absences appropriately and in a timely manner; has unexcused absences without appropriate justification c. does not complete non-academic compliance requirements by deadlines (e.g. immunization status, registration, course evaluation, required on-line training) d. does not maintain accurate contact information with the SOM, does not respond to emails and phone calls promptly

5. Humility, Empathy and Compassion a. appears callous, dispassionate, or insensitive in the face of others’ suffering or distress b. self-promoting or arrogant c. negatively competitive with peers or team members 6. Professional Boundaries a. exhibits inappropriate use of social interaction, language, humor, physical contact or self-disclosure in interactions with patients, families, peers, team members or staff b. not aware of or exceeds limits of medical student role c identifies self as a doctor d. fails to maintain the confidentiality of patient’s concerns or care e. makes inappropriate disclosures about self, patients, or institution on internet/social networking sites f. not responsive to education regarding professional boundaries

7. other (please describe in detail below)

Description of event(s) or observation(s) leading to completion of this form: ______

(If you do not plan to discuss this notification with the student, please return this form as instructed below. Faculty members are expected to discuss this notification with the student)

Student verification:

I have read this form and discussed it with the person completing it or the course director:

______Student signature Date report was discussed

My response to this notification or plan for remediation is: ______

PLEASE RETURN THIS FORM TO THE OFFICE OF STUDENT AFFAIRS at BOX 3005, DUMC, Durham, NC 27710, or by email to Barbara Gentry at [email protected]

I have discussed this notification with my advisory dean, ______(name)

Student signature______Date notification was discussed______

Advisory Dean signature______Date______