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Samaan

Fadi

Samaan

CONFIDENTIAL SURVEY

Preliminary Internal Medicine Resident Concerns Form

A confidential form for preliminary internal medicine residents to report concerns, mistreatment, suggestions, and observations. Take your time — share only what you’re comfortable with.

Your responses are confidential. Submissions are reviewed only by the resident representative.

IN THIS FORM

About you

Type of concern

Your experience

Severity

Details

Questions marked * are required. Everything else is optional.

STEP 01

About you

Submission type *

Anonymous — don’t include my identity

Include my name (only visible to rep)

Your name

Only if you chose “Include my name.” Leave blank to stay anonymous.

STEP 02

Type of concern

Select all that apply

Mistreatment

Harassment or discrimination

Workload / wellness concern

Educational or supervision concern

Patient safety concern

Suggestion or improvement

Other

STEP 03

Your experience

Did you experience or witness this? *

I personally experienced this

I witnessed this happen to someone else

Both

Who was involved?

Select all that apply

Co-intern / fellow intern

Senior resident

Fellow

Consultant / attending

Nursing or allied health staff

Administrative staff

Patient or family member

Unsure / prefer not to say

Where did this occur?

How often has this occurred?

STEP 04

Severity

How much has this affected you? *

Mild

Moderate

Significant

Severe

STEP 05

Details

Please describe what happened *

You don’t need to name anyone — describe the situation in your own words.

Has any action been taken so far?

What kind of support are you looking for?

I just want this acknowledged

Help identifying if this is a broader pattern

Help escalating formally

Connect me with support resources

Not sure yet

Anything else you’d like to add?

Reviewed only by your resident representative

You don’t need to name anyone

Follow-up where possible

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