Student Concern Report

Please use the following form to submit concerning behavior exhibited by a student at the Oklahoma State University College of Osteopathic Medicine. If you are submitting this report for unprofessional behavior, you should speak directly to the student to address the behavior unless you would prefer a member of the Student Concern Report Committee speak to the student. Upon submitting a report, no one from the Student Concern Report Committee will speak to the student unless you request someone speak to the student or the behavior rises to a level that compels a conversation with the student. In the event the student's behavior prompts a conversation with the committee, the committee will notify you first.

First Name of Person Submitting This Report

Last Name of Person Submitting This Report

Email Address of Person Submitting This Report

Student's First Name

Student's Last Name

Date of Event

Nature of Report

Missed Required Event (e.g., Guest Lecture, Clinical Problem Solving, Rescheduled Exam/Quiz, Experiential Education, etc.)

Unprofessional Behavior

Other (please describe below)

What required event or exam did the student miss or reschedule?

Did the student provide an excuse?

Yes

No

Was the absence or rescheduling excused?

Yes

No

Was the absence or rescheduling pre-approved?

Yes

No

What excuse did the student provide?

If available, please provide any additional information regarding why the student did not provide an excuse.

Please describe conduct:

Do you believe this event warrants the issuance of a non-cognitive grade?

Yes

No

You may submit a Non-Cognitive Grade Report here: https://medicine.okstate.edu/site-files/documents/com/academic-affairs/noncogform.pdf.

Do you want someone from the Student Concern Report Committee to speak to the student about the conduct submitted in this report?

Yes

No

If you would like to submit attachments, emails, or other information that is not contained in this report, please email it to carrie.gilstrap@okstate.edu.

Thank you!