The purpose of this form is to report the experienced mistreatment of students from Emory School of Medicine while engaged in educational activities. Mistreatment, either intentional or unintentional, occurs when behavior shows disrespect for the dignity of others an unreasonably interferes with the learning process. Mistreatment of the School of Medicine student will not be tolerated and your submission via this form is used to help SOM leadership evaluate concerns and assess next steps. Thank you in advance for your submission.

When completing this form, please include as much detail as possible.

Once submitted, all reports of mistreatment will be evaluated as soon as it is received. If this matter requires urgent attention, please reach out directly to the Associate Dean of Student Success at christen.hairston@emory.edu or by phone at 864-401-1888. 

Reports that involve the University's Sex and Gender Based Harassment Policy will be referred to the University's Title IX Office for follow-up. (Sex and Gender Based Harassment and Discrimination Policy 8.2). Reports that involve discrimination and/or harassment of any individual or group based upon race, color, religion, ethnic or national origin, gender, genetic information, age, disability, sexual orientation, gender identity, gender expression, veteran's status, or any factor that is a prohibited consideration under applicable law will be referred to the University's Department of Equity and Inclusion for follow-up. (Equal Opportunity and Discriminatory Harassment Policy 1.3).  

Reports of bias in the curriculum should not be reported using this form. Such reports for MD students should be submitted using the following link:  https://emorymedicine.sjc1.qualtrics.com/jfe/form/SV_1FXqui8JGjaEX9s. Such reports for all other SOM students should be submitted by emailing Dr. Douglas Ander, Assistant Dean for Medical Education at dander@emory.edu. 

By submitting this report of student mistreatment, you understand that:
  • The School of Medicine takes all allegations of student mistreatment very seriously.
  • We seek to protect all students.
  • We seek to keep the reporting and experience of mistreatment confidential only to the leaders, faculty, and/or staff who are essential to the process.
  • There are rare instances in which the individual who submitted this form must be revealed. These rare instances include but are not limited to imminent risk of serious harm to students or others, criminal matters, and/or Title IX mandated reporting.
  • The option to submit this form anonymously is there, but please note that this limits the SOM leadership's ability to follow-up with you for additional information.
Academic program for Emory SOM student who experienced mistreatment.
Level in program of student who was mistreated. 
Please indicate the category of mistreatment. Check all that apply.