College of Medicine Medical Student Concern Form

Student name

Student campus

Notification emails

Setting

Add name of course, clerkship, other

Location

Hershey, UP, or list other site

Faculty/Staff member completing form

Select which medical student competencies apply to this form. (View the competencies with subcompetencies.)

Patient Care: Provide patient-centered care that is compassionate, appropriate, and effective for the promotion of health and treatment of health problemsKnowledge for Practice: Demonstrate knowledge of and critical thinking about established and evolving biomedical, clinical, and health systems sciences, as well as health humanities, and apply this knowledge to patient care.Practice-Based Learning and Improvement: Demonstrate the ability to investigate and evaluate one’s care of patients, to appraise and assimilate evidence and emerging research, and to improve patient care through a practice of being reflective and engaging in life-long learning.Interpersonal and Communication Skills: Demonstrate verbal and non-verbal communication skills that show respect for and result in effective exchange of information and collaboration with patients, their families, and health professionals.Professional Behaviors: Demonstrate professional behavior with patients and families, teams, health systems, and society.Systems-Based Practice: Demonstrate an awareness of and responsiveness to the larger context and system of health care and public health, as well as the ability to call effectively on other resources in the system to provide optimal health care.Health Humanities: Approach patients as whole persons, demonstrating compassion, humility, and respect.

Description of the concern. In your description, please only include a description of the behavior associated with your concern. Please do not include your interpretation of the behavior. Include date of incident(s) in your description.