The code block below illustrates how one might use # and // as comments in your logic and calculations.

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wHbwyDIFBjxpX2Z4hGffUYnkbwqUQq7oXJQgEajS7VaMMiKWF5SVdRFsXF589dHfShjzWtbh9RMYbvvYyEIFkWjSef5PUuM

Women's College Hospital Learner Incident Disclosure Form

The Women's College Hospital Learner Incident Disclosure Form is a confidential online tool that learners, preceptors, staff, and volunteers can use to provide information regarding any behaviour experienced or witnessed that a learner perceives or suspects to be mistreatment.

You have the option to submit this form anonymously (i.e. without the requirement that you provide your identity), with the understanding that doing so may make it more difficult for us to follow up with you to make sure you get support, to ensure that we have all the necessary details, and to report back to you regarding the status of your disclosure or its outcomes. It may also limit our ability to take action on the matter in certain cases. Note that you can submit an identified disclosure and tell us not to escalate the matter until we speak with you first and help you to understand all your options, including how we can protect your confidentiality.

At your request, the designated Learning Institute member will aim to contact you within 3 business days to initiate a discussion about possible next steps and supports.

For additional resources and guidance on the different support pathways, please refer to our Learner Assistance page.

Learners may also choose to contact their educational institution's dedicated pathway:

For University of Toronto undergraduate and postgraduate medical learners: Please refer to the Temerty Faculty of Medicine "Learner Mistreatment" guidelines for disclosing/reporting mistreatment, which also include options for anonymous reporting through the Learner Experience Office in the Temerty Faculty of Medicine
For University of Toronto pharmacy students: Please contact the Office of Experiential Education (OEE).

I am a

* must provide value

Type of health discipline student

Other

Did you

* must provide value

Experience mistreatment

Witness mistreatment

Overheard mistreatment

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Enter single or multiple dates of occurrences

* must provide value

Enter the location of the incident. If the incident took place in more than one location, please indicate.

* must provide value

Type of behaviour. Please select all that apply.

* must provide value

Unprofessional behaviour

Discrimination or discriminatory harassment

Sexual violence or sexual harassment

Unsure

Other

Describe the behaviour that was experienced, witnessed, or overheard. If you prefer to speak with someone in person or over the phone, please indicate.

Some questions you may want to consider in your response below include:

Who was responsible for the unprofessional behavior?
Who else was there as a witness? (please do not include patient names or identifiers)
What happened, to the best of your memory?
Where did this occur (including details of the course, event, or rotation)?
When did this occur? Single event or recurring events?
How would you describe what you experienced? What was the impact on you?
Did you perceive the mistreatment to be attributed to your identification with a specific minority group?
Are there any other factors that you think would be helpful to record?

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Who should receive this form?

* must provide value

Director, Learning Institute

Manager, Learner & Student Services

Any of the 2 persons above

If you wish to be identified and followed up with, please include your name and email. If you wish to submit this anonymously, please leave this question blank.

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.