Southern Illinois University School of Medicine

Southern Illinois University School of Medicine Office of Residency Affairs


Report A Concern


I have a concern about:

If "other" please describe
Your Name*
(We cannot accept anonymous reports. This is necessary because anonymous reporting can lead to lower report quality and hampers our ability to fully evaluate the concern.)
  Date(s) the incident occured:
  Clinical site/location where incident occurred:
(Please include the name of the hospital or clinic and floor/unit)
  Specify what happened:
  Who are the individuals involved in the incident?
  Who did you notify?
  Who witnessed the incident?
  Please specify any contributing factors:
  What is your suggestion as how best to address this concern?
  Would you like someone to follow up with you as to how this concern has been addressed?

If YES, what is your preferred method to be contacted?



  Provide contact specifics (email address, phone number, other)
"The mission of the SIU School of Medicine is to assist the people of central and southern Illinois in meeting their health care needs through education, patient care, research, and service to the community."


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