Mistreatment Reporting Form

* - required field

Mistreatment Information

* I have read the definition of mistreatment posted on the "Information for Students" website


* Having read the definition of student mistreatment, I believe that I suffered mistreatment as a student that was outside the bounds of acceptable behavior.

* Please describe the behavior or incident

**disclaimer - all instances that fall under Title IX will go through those channels

* Please choose the best descriptor of the inappropriate behavior (choose all that apply).


Please Specify:

Note: Any discriminatory behavior or sexual mistreatment or misconduct must be reported pursuant to Einstein’s Non-Discrimination and Gender-Based Misconduct Policy and Complaint Procedures for Students (which must be reported pursuant to that policy).


* The individual I hold responsible for this behavior is:


Please Specify:


The name of the individual you are complaining about is: (optional)

6. Rotation or elective (optional)
7. Rotation or elective site (optional)
8. Pre-clinical Course (optional)
9. * Your Name
10. * Your Email Address: Please enter an Einstein med email address
username@med.einstein.yu.edu or username@mail.einstein.yu.edu