Professionalism Concern Form The Zucker School of Medicine lists Professionalism as one of the 10 essential values to guide and shape the development of our school. If you feel you have witnessed a violation of professionalism by a student please take the following steps: complete Part A of the form, contact and address the concern with the student, obtain the student’s signature at the end of Part A and submit the form tosom.professionalism@hofstra.edu with the student CC'ed. The student will then have 10 business days from date of submission to respond with Part B. It is expected that when a student displays a professionalism concern it is discussed with the student in a timely fashion.

Name of Student Involved: Date of Incident: (Full Name) (mm/dd/yy)

Student Status at Time of Incident: First 100 Weeks

Second 100 Weeks

Joint Degree Program

Institutional (Outside of Formal Curriculum)

Below are examples of professionalism concerns, as defined by the Statement of Professionalism. Describe the professionalism concern using the options below. Under each dimension, please use the mandatory comment boxes to record details related to the concern.

The above student did not meet expectations in the following area(s):

1. AccountabilityStudent failed to take responsibility, acknowledge academic short-comings, or admit to mistakes. Student reacted defensively to constructive criticism. Student failed to address physical, personal, or psychological limitations that affect professional performance (i.e. burnout). Other:

If one of the above options for Accountability is selected, documentation describing the concern is required for this section

PART A – Incident Documents

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2. Aspiring to ExcellenceStudent appeared uninterested or disengaged in curricular or community activities. Student lets major errors in work go uncorrected or unaddressed. Student was unprepared for curricular activities which impacted community members (i.e. PEARLS). Other:

3. Conscientiousness

Student failed to attend, arrived late, or left early for required curricular or clinical responsibilities. Student did not recognize significant errors and/or does not consult colleagues when appropriate. Student was not thorough or systematic in approaching tasks. Other:

4. Equanimity

Student lost composure, said or did inappropriate things, became argumentative or uncivil. Student displayed poor decision making skills Other:

If one of the above options for Aspiring to Excellence is selected, documentation describing the concern is required for this section

If one of the above options for Conscientiousness is selected, documentation describing the concern is required for this section

If one of the above options for Equanimity is selected, documentation describing the concern is required for this section

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5. IntegrityStudent engaged in conduct that put patients or their privacy at risk, such as misrepresented a medical record or engaged in a conflict of interest. Student knowingly disregarded rules, regulations, or failed to comply with school, university or health system policies and procedures. Student did not adhere to personal appearance standards (i.e. inappropriate dress or remaining free from the influence of alcohol, illegal drugs and other substances while at educational or clinical activities).Student used status for personal gain, wasted, or mismanaged institutional resources or personnel. Student failed to uphold ethical standards, plagiarized, or mismanaged information. Other:

6. Patient-CenterednessStudent put individual needs above those of the patient, failed to advocate on behalf of the patient, or did not provide complete, accurate information when answering questions or acknowledge decisions ultimately rest with patient. Student demonstrated no interest in relieving pain, suffering, or lacked empathy. Student appeared passive and unengaged with patients, used pejorative terms to refer to patients (i.e. hits), or did not follow up or encourage questions. Student did not anticipate safe handoffs or put patient at risk. Student discriminated, displayed a lack of tolerance, or disrespected patients or families, based on age, gender, race, culture, nationality, religion, socioeconomic status, etc. (i.e. used inappropriate language, did not use interpretive services when needed). Other:

7. Teamwork

Student refused to help or did not volunteer for colleagues when asked for assistance. Student discouraged idea sharing, collaboration or dominated team conversation or action. Student actions reflected bias or partial treatment toward certain team members, such as inappropriately excluded team members from team activities. Student blamed coworkers for errors that were not their fault. Student demonstrated a lack of respect for teammates or criticized colleagues in public in a disrespectful manner. Student failed to demonstrate respectful interaction and etiquette in some form of communication.Other:

If one of the above options for Integrity is selected, documentation describing the concern is required for this section

If one of the above options for Patient-Centeredness is selected, documentation describing the concern is required for this section.

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Use the space below to document the discussion with the student about the professionalism concern described above.

If one of the above options for Teamwork is selected, documentation describing the concern is required for this section.

Please use this section to document and emphasize details about the conversation.

Part A completed by: Signature:

Date form was discussed with Student:

I, , discussed the professionalism concern with I understand that I have 10 business days from submission of Part A in which to respond by completing and submitting Part B of the Professionalism Concern Form to som.professionalism@hofstra.edu. Failure to submit Part B in time will result in the Professionalism Committee evaluating the concern without Part B.

Student Signature:Once signatures have been obtained and form is complete please email Part A to som.professionalism@hofstra.edu and CC the student.

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False AllegationsIntentionally making false accusations can have a negative impact on the individuals involved and the community. An individual who knowingly and intentionally files a false complaint under this policy is subject to discipline.

PART B – Student Documents

Student Signature: Date:

Part B must be completed by the student with identified professionalism concern within ten business days from submission of Part A. Part B should be submitted to som.professionalism@hofstra.edu for review by the Professionalism Committee at their next scheduled meeting. Failure to submit Part B in time will result in the committee continuing to evaluate concern without Part B.

Please document your account of the professionalism concern described above and the discussion that took place that was described in Part A.

Student Comments:

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False AllegationsIntentionally making false accusations can have a negative impact on the individuals involved and thecommunity. An individual who knowingly and intentionally files a false complaint under this policy issubject to discipline.