HARVARD MEDICAL SCHOOL – LEARNING ENVIRONMENT CONCERN / MISTREATMENT REPORT FORM

If you have any immediate concerns about your safety or well‑being, or that of someone else, please seek urgent assistance through emergency services or appropriate HMS support resources.

We encourage you to use this form to report any concern in the learning environment, including mistreatment. This form can be used by the student experiencing an issue or anyone who has observed a concerning incident.

The information submitted in this report will be reviewed by the HMS Dean for Students and the HMS Senior Director of Student Affairs. Please note that all personally identifiable information will be handled with strict confidentiality, unless there is danger or concern for anyone's health and safety.

You may submit this form anonymously. Reporting an incident anonymously reduces our ability to fully investigate the incident. However, a record of the incident will be entered into the incident reporting database for future tracking and reporting purposes.

Policies regarding mistreatment can be found in the HMS Student Handbook.

Reported incidents are treated seriously and responded to appropriately, fairly and expeditiously. HMS has a zero-tolerance policy for student mistreatment and retaliation.

Please provide information as follows: ( Required fields)*

SECTION 1 – BASIC INFORMATION

SECTION 2 – DESCRIPTION OF BEHAVIOR

Please check all that apply to the incident you are reporting whether you experienced or witnessed them personally:

SECTION 3 – BIASED OR DISCRIMINATORY MISTREATMENT

I personally experienced or witnessed:

SECTION 4 – RETALIATION OR THREATS OF RETALIATION

SECTION 5 – PERSON(S) INVOLVED

SECTION 6 – NARRATIVE DESCRIPTION