Auto Report Date and Time
Today M-D-Y
I am:
* must provide value
Making a new report
Entering data about a report that's been addressed/resolved; or, entering information about a report made directly to me outside of this system (i.e., in person, or via email or other form of communication)
The "entering data' option is to be completed by HR professionals, Associate Deans for Students Affairs, or other KUMC staff with the responsibility of investigating student and staff concerns.
Reporter's first name:(Please note: A concern can be reported anonymously, and this field along with "last name" and "email address" are optional. As with all reports submitted, every effort will be made to follow up on anonymously-reported concerns; however, please know that without the ability to follow up with the reporter, an anonymous report may be more difficult to invesitgate.)
optional
optional
Reporter's email address:
optional
I am a:
* must provide value
Faculty member
Staff member
Health Professions student
Medical student
Nursing student
Resident/Fellow
Graduate student
Postdoc
Other
If "Other," please describe:
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I am making this concern report on behalf of:
* must provide value
Myself
A peer, student, colleague or coworker
I am reporting the following concern: Please note: If the behavior you're reporting involves sexual harassment, please complete the Title IX intake form, located at https://redcap.kumc.edu/surveys/?s=E9EL7AYDXH , instead of this Concerning Behavior Reporting Tool.
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Behavior perceived as a risk and/or threat to my personal safety
Behavior perceived as a risk and/or threat to the safety of a peer, student, colleague or coworker
Disrespectful, demeaning or humiliating treatment or behavior
Self-harming behavior
Discriminatory behavior
Other
If "Other," please describe:
* must provide value
Approximate date the concern(s) arose or the concerning behavior occurred:
* must provide value
Today M-D-Y
The concerning behavior occurred at:
* must provide value
Kansas City or its affiliate sites
Salina or its affiliate sites
Wichita or its affiliate sites
Other
"Affiliate site" refers to, for example, a location a student might be rotating at as part of her/his curriculum.
If "Other," please describe:
* must provide value
The concerning behavior was exhibited by a:(Please note that all reports received via REDCap will be routed to an appropriate administrator/department for review and handling. For transparency's sake, KUMC wants to make it clear how your report will be directed. Reports concerning faculty and staff members, including residents/fellows, will be routed to Human Resources; reports concerning students in the Schools of Health Professions, Medicine and Nursing will be routed to that school's Associate Dean for Student Affairs; reports concerning graduate students and postdocs will be routed to the Dean of Postdoctoral Affairs and Graduate Studies; and reports regarding "others" will be routed to the Safety Intervention Team for review and further distribution.)
* must provide value
Faculty member
Staff member
Health Professions student
Medical student
Nursing student
Resident/Fellow
Graduate student
Postdoc
Other
If "Other," please describe:
* must provide value
Name of individual(s) being reported:
* must provide value
Describe the concerning behavior of the individual(s) being reported:
* must provide value
Have you previously reported these concerns?
* must provide value
Yes
No
When?
* must provide value
Today M-D-Y
Were these concerns resolved at that time?
* must provide value
Yes
No
Your first name:
* must provide value
Your last name:
* must provide value
Your position:
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Your email address:
* must provide value
Entering information about a concern originally submitted through this system and which I've addressed/resolved
Entering information about a concern not originally submitted through this system, but rather was made to me some other way (e.g., in person, via email, etc.), and which I've addressed/resolved
Corresponding Report Number:
* must provide value
The report number must be included if you're entering data about an addressed/resolved concern originally submitted through this system.
Date concern(s) was/were reported to you?
* must provide value
Today M-D-Y
Do not include reporter's name if confidentiality was requested
Do not include reporter's name if confidentiality was requested
Reporter's email address:
Do not include reporter's email address if confidentiality was requested
Reporter is a:
* must provide value
Faculty member
Staff member
Health Professions student
Medical student
Nursing student
Resident/Fellow
Graduate student
Postdoc
Other
If "Other," please describe:
* must provide value
Reporter reported the following concern:
* must provide value
Behavior perceived as a risk and/or threat to my personal safety
Behavior perceived as a risk and/or threat to the safety of a peer, student, colleague or coworker
Disrespectful, demeaning or humiliating treatment or behavior
Self-harming behavior
Discriminatory behavior
Other
If "Other," please describe:
* must provide value
Approximate date the concern(s) arose or the concerning behavior occurred:
* must provide value
Today M-D-Y
The concerning behavior occurred at:
* must provide value
Kansas City or its affiliate sites
Salina or its affiliate sites
Wichita or its affiliate sites
Other
If "Other," please describe:
* must provide value
The concerning behavior was exhibited by a:
* must provide value
Faculty member
Staff member
Health Professions student
Medical student
Nursing student
Resident/Fellow
Graduate student
Postdoc
Other
If "Other," please describe:
* must provide value
Name of individual(s) being reported:
* must provide value
Describe the concerning behavior of the individual(s) being reported:
* must provide value
Have these concerns been fully investigated and resolved?
* must provide value
Yes
No
Please list who was involved in addressing the reporter's concern(s):
* must provide value
How was/were the concern(s) addressed:
* must provide value
Date the concern(s) was/were addressed and resolved:
* must provide value
Today M-D-Y
Are additional resources needed to resolve this/these concern(s)?
* must provide value
Yes
No
If yes, what additional resources are needed?
