Unprofessional Behaviour, Discrimination and Harassment Reporting Form

This form is to be used to report behavior that may contravene Schulich’s Code of Conduct, Western’s Policy on Discrimination and Harassment and/or the Schulich School of Medicine & Dentistry’s Professionalism Policies. As a Learner, you may report an instance of unprofessionalism or mistreatment as either a witness or a person who was directly involved in the situation.   The procedure for making a report is outlined in the Schulich Code of Conduct and in the  Professionalism Policy.  Please note that submitting this form does not mean that action will necessarily be taken.  In most cases, you will be offered a confidential consultation with Schulich’s Learner Equity & Wellness (LEW) Office  or the most appropriate support office for your concern.  

The information you submit will be sent to LEW via email.  A copy will also be sent to the email address you have provided on the form for your records.  If you prefer, you may print the PDF version of this form, fill it out by hand and send it to our office via campus mail.  

All reports are maintained as per the practices of Learner Equity & Wellness (LEW), including confidentiality and file retention.

Should you require this form in an alternate format or need assistance completing this form, please call LEW at 519-661-4234/519-253-3000 x 4302 (Windsor).  
Please note LEW does not provide copies of the completed form.  Please ensure that you print and retain a copy for your own records if desired.