Professionalism Behavior Concern Form | Burnett School of Medicine at TCU

I Am Referring The Following:
Course/Clerkship/Facility
Person Reporting (Leave Blank For Anonymous)
Date of Incident
Date Format: MM slash DD slash YYYY
If this incident involves a student, staff or faculty member, was it discussed with that person?
- Yes
- No

Concerns About Students, Staff, or Faculty
Unmet Professional Responsibility:
- The individual exhibits unprofessional dress in front of patients and/or peers.
- The individual lacks punctuality with important duties.
- The individual fails to finish important tasks or assignments.
- The individual cannot be relied upon to communicate effectively.
- The individual needs continual reminders in the fulfillment of responsibilities that are essential to being a medical student/faculty/staff member at TCU and UNTHSC School of Medicine (ie: responding to emails, completing immunization or USMLE exams by the required dates.)
- Concern regarding ethics or unethical behavior
Comments
Lack of Effort Toward Self Improvement and Adaptability:
- The individual is resistant or defensive in accepting criticism.
- The individual remains unaware of their own inadequacies.
- The individual resists considering or making changes.
- The individual does not accept blame for failure or responsibility for errors.
- The individual is abusive or critical during times of stress.
- The individual demonstrates arrogance.
- Other
Other Concern
Comments
Diminished Relationships with Patients and Families:
- The individual inadequately establishes rapport with patients or families.
- The individual is often insensitive to the patients' or families' feelings, needs or wishes.
- The individual lacks empathy.
- The individual has inadequate personal commitment to honoring the wishes of the patients.
- Other
Other Concern
Comments
Diminished Relationships with Members of the Health Care Team:
- The individual does not function adequately within a health care team.
- The individual's behavior towards peers is interfering with group learning.
- The individual is insensitive to the needs, feelings, and wishes of the health care team members.
- The individual cannot be relied upon to communicate effectively.
- The individual misrepresents or falsifies actions and/or information.
Comments
Diminished Relationships with Administrative Faculty or Staff:
- The individual behaves in an inappropriate manner with administrative faculty and staff (e.g. does not respect the professional role of the administrator).
- The individual does not respect professional boundaries in interactions with students, faculty or staff.
- Other
Other Concern
Comments

Concerns About Students, Staff, or Faculty