School
Year

Please indicate how well you feel that you have been prepared to meet the Fundamental Principles and Professional Responsibilities described in the Charter on Medical Professionalism.

Select One Not at all Poorly Satisfactorily Well-prepared

Please indicate which methods would be most helpful for learning about professionalism.

Structured lecture	Select One Not Effective Somewhat Effective Very Effective
Small group discussions	Select One Not Effective Somewhat Effective Very Effective
Observing others	Select One Not Effective Somewhat Effective Very Effective
Message board	Select One Not Effective Somewhat Effective Very Effective
Other

Have you witnessed any of the following unprofessional behaviors? Please check the columns that apply. If you witnessed one of these bahaviors but did not report it, please indicate why in the Comments fields.

Behavior Type	By Whom?	Did you report it?	Comments
Abuses of Power
Breach of Confidentiality		Yes No
Interactions with Patients & Colleagues		Yes No
Bias and Sexual Harassment		Yes No
Negotiating Power Asymmetries		Yes No
Arrogance		Yes No
Greed		Yes No
Misrepresentation		Yes No
Impairment (Eg. Substance abuse, lack of sleep)		Yes No
Lack of Conscientiousness		Yes No
Conflicts of Interest
Self-Referral		Yes No
Acceptance of Gifts		Yes No
Utilization of Services		Yes No
Collaboration with Industry		Yes No
Compromising the Principles of Investigation		Yes No
Conflicts of Conscience		Yes No

Do you feel that it would be appropriate for each medical school to adopt Dr. Cohen's Compact Between Teachers & Learners of Medicine?

Select One Yes No

Please feel free to add any comments: