MILES Committee
Mistreatment Incident and Learning Environment Surveillance

Form to Report Student Mistreatment

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If you or another person is in imminent physical or psychological danger, please call 911 or contact Public Safety (410-955-5585), or the Behavioral Health Crisis Support Team (410-516-WELL).

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Instructions
Fill out the form below to report mistreatment. All fields marked with a * are required.
Select the submit button when finished.

Submitter Information

      Report Anonymously

Anonymous claims will be confidentially investigated, maintaining complainant anonymity to the extent possible, however, based on facts of a case, anonymity cannot be guaranteed. Anonymous complaints will be logged and investigated to the extent possible, however, without the ability to obtain additional information from the complainant/reporter, be advised that it is difficult to process such investigations.

Last Name * This field is required

First Name * This field is required

Email * This field is required

Confirm Email * The Emails are not match

If you provide a non-Hopkins email, there are limits to ensuring the security of your email.

Year of Medical School *       This field is required        1 2 3 4

Other (please specify)

Mistreatment Information

Subject of Mistreatment * This field is required Select Type Self Another person (student or otherwise) whom you witnessed being mistreated Someone who told me about this incident

Clinical or Pre-clinical?
Clinical/LC Preclinical/TIME Other (Research Year, etc)

Clinical Site *This field is required Select Site JHH JH Bayview Sinai Howard County St. Agnes All Children's Other

Learning Environment *This field is required Select Site Core Elective Subinternship Longitudinal Clerkship (LC) Advanced Critical Care Clerkship/ICU

Sub-speciality Select Site Core Elective Subinternship Longitudinal Clerkship (LC) Advanced Critical Care Clerkship/ICU

Other Subinternship:

Other Clinical Site:

Electives Book: Johns Hopkins School of Medicine

Time Period Event Occurred

Month *This field is required Select Month January February March April May June July August September October November December

Year *This field is required Select Year 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025

QuarterThis field is required Select Quarter Quarter 1 Quarter 2 Quarter 3 Quarter 4 Summer

Year of Medical School when Incident Occurred *This field is required
1 2 3 4

Other (please specify)

Source of Negative Behavior

If you do not remember the person's name, put "not sure" in the first and last name fields.

Last Name *This field is required

First Name *This field is required

Position *This field is required
Attending Resident Nurse Fellow Other Medical Student

Other (please specify):

Other Notes

Please list any other information about the Source of Negative Behavior. For example, if you cannot remember exactly who it was, please describe the person and their position. If it was multiple people or an entire team involved in the mistreatment, please list them here.

Description of Mistreatment

Description *This field is required

Please describe the incident(s) in as much detail as you possibly can and you are comfortable sharing.

If you would rather schedule a meeting to discuss the details in person, please indicate that here.

Type(s) of Conduct, Behavior, or Conditions * This field is required

Please choose all that feel relevant to the incident in question. Do not worry about “official definitions” of these terms; these we will be used by the Office to help organize reports and detect broader trends or issues in the learning environment.

Bullying

Inappropriate email, social media, text message, phone, or other contact

Unsafe environment

Harassment

Intimidation

Inappropriate / discriminatory comment

Microaggression

Retaliation

Perceived unequal treatment

Inappropriate or unnecessary physical contact

Physical assault

Property damage / vandalism

Sexual assault

Stalking

Threat of physical assault

Bias/discrimination based on race, ethnicity, gender identity, sex, sexual orientation, body weight, religion, socio-economic status, age, nationality, culture, pregnancy status, disability, mental health, marital status, career plans, family plans

Unwanted sexual conduct/sexual harassment

Verbal assault

Threatening statements (e.g., threat of outing)

Written hate speech or graffiti (written or internet)

Concern about potential harm of a minor

Other (please specify)

Urgent

Please select Yes if you believe this is an urgent matter to be handled immediately.

Yes No

What level of follow-up would you like? *

This field is required

I only wanted to file a complaint with no additional follow-up.

There are circumstances under which follow-up might be required.

I am willing to be contacted for follow-up, if necessary.
I would like to discuss the event with an Ombuds in person.

Are there any particular people on the committee whom you do not want privy to your report or who have a conflict of interest?

As a reminder, here is a link to the committee membership.

Are there any other considerations you would like taken into account when selecting the Ombuds who will review your report (and meet with you, if you selected that option)?

As a reminder, here is a link to the committee membership. We cannot guarantee that a particular faculty member might be available.

Is there anyone else with whom you would like to discuss your report, or whom you would like notified/involved?

Have you discussed this report with anyone else?
Yes No Do Not Remember

Who? (Check all that apply)

Offender

Other medical student/peer

Friend

Family

CAP advisor

OSA

Clerkship director

Chair of Dept

Police

Other

Please share anything you wish about your experience reporting to other people, including whether you feel it was handled appropriately and what motivated you to also submit to the Ombuds Office.

If you have any additional questions or concerns, please list them here:

Demographics

This section is used for data-gathering and detection of troubling patterns. It is ENTIRELY OPTIONAL.

Gender Identity

What is your current gender identity? Please select all that apply.

Male

Female

Trans man/Transmasculine

Trans woman/Transfeminine

Non-binary

Genderqueer

Different identity

Choose not to answer

What sex were you assigned at birth, on your original birth certificate?

Male Female Choose not to answer

Race

Select all that apply

Asian

American Indian or Alaska Native

Black or African American

Native Hawaiian or Other Pacific Island

White or Caucasian

Ethnicity

Hispanic or Latino

Sexual Orientation

Do you consider yourself to be: - Selected Choice

Straight Lesbian or Gay Bisexual
Different orientation Don't know Choose not to answer

How were you made aware of the Office of the Ombuds?

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