School of Medicine Aggie Awareness Reporting Form

Reporting Exemplary and Concerning Behaviors

Fill out the request form below. We will reach out to you within seven calendar days after you have submitted your request.

Your Name (Optional) Your Name (Optional) First Last
Your Email (optional)
I am a:

I am a: Faculty Member Staff Member Medical Student Resident/Fellow Graduate Student Other Other
Reporting an Aggie conduct of Exemplary or Concerning Action *
Questions to ask yourself before reporting
- Have I observed this behavior more than once?
- What are the pros and cons of reporting vs. addressing this myself?
- Was this behavior done in a perceived negative or malicious manner?
- Can I handle this myself with a brief conversation? Why or why not?
I am reporting a:

I am reporting a: Faculty Member Staff Member Medical Student Resident/Fellow Graduate Student Other Other
Approximate date of behavior Approximate date of behavior / MM / DD YYYY
Exemplary Action *

Exemplary Action Excellence Respect Integrity Leadership Loyalty Selfless-Service
Where this occurred *

Where this occurred Bryan/College Station or its affiliate sites Dallas or its affiliate sites Houston or its affiliate sites Round Rock/Austin or its affiliate sites Temple or its affiliate sites Other
If other, please identify the site
Name of individual(s) to be acknowledged for their Exemplary Action *
Describe the details of the Exemplary Action *
Concerning Action *

Concerning Action Excellence Respect Integrity Leadership Loyalty Selfless-Service
Where this occurred *

Where this occurred Bryan/College Station or its affiliate sites Dallas or its affiliate sites Houston or its affiliate sites Round Rock/Austin or its affiliate sites Temple or its affiliate sites Other
If other, please identify the site
Name of the individual(s) involved in the Concerning Action *
If the concerning action has already been addressed, please list who addressed the action If the concerning action has already been addressed, please list who addressed the action First Last
If the concerning action has already been addressed, please list how the action was addressed
If the concerning action has already been addressed, please indicate the approximate date the concerning action was addressed If the concerning action has already been addressed, please indicate the approximate date the concerning action was addressed / MM / DD YYYY
Describe the details of the Concerning Action (please describe to the best of your knowledge the circumstances and behavior that you witnessed in the learning environment and pertinent facts around the interaction: *

School of Medicine Aggie Awareness Reporting Form

School of Medicine Aggie Awareness Reporting Form

Questions to ask yourself before reporting