This form has been provided so that you can anonymously report concerns, complaints, and/or perceived violations specific to your residency or fellowship training program. Submissions are anonymously delivered directly to the Harbor-UCLA’s Graduate Medical Education leadership and are taken very seriously.

Subject (required)

Select from one of the following categories from ACGME resident Survey (required)
ProfessionalismResourcesDuty HoursEducational ContentFaculty Teaching & SupervisionOther
Description of Concern (required):

The following fields are not required, but may be helpful for GME to better understand and address the concerns.
Location if applicable (OR, clinic, etc…) (not required)

Timing of event (day/time) (not required)

Individuals involved (not required)

Training Program Involved (not required)

Has PD or anyone from your program leadership been notified? Yes or No. (not required)
If yes, optional to include the name of person notified
Select Yes or No (required)
YesNo
If yes, optional to include the name of person notified

Are you willing to be contacted? If so, please provide your name and contact info (email). If you provide this, all information will be kept confidential (not required)

Is there an outcome you hope for? Please describe (not required)