Raise Concern

Student name

Student ID

(Note to students: This is the name of the student you wish to raise the concern against, not your own name. Your name should be entered in the 'Raised by' field below.)

Concern Level Select Level Major Concern Moderate Concern Minor Concern

Concern Category Select a Category Unmet professional responsibility Lack of effort toward self improvement and adaptability Diminished relationships with patients and families Diminished relationships with members of the health care team Health grounds Academic performance Breach of university regulations Other

Concern Subcategory You must select a category first

Notify Senior Tutor

Comment
Please be aware that all text you enter here will be visible to the student

Raised by

Position

On behalf of

Location Select the location of the person who raised the concern Buckingham Campus Crewe Campus GP surgery Leighton Hospital Macclesfield Hospital Milton Keynes Hospital Not specified St Andrews Hospital Stoke Mandeville Hospital - BHT The Railings Warwick Hospital - SWFT

If the person who raised the concern wishes to receive feedback that their concern has been logged, enter their email address below. Leave this blank if they do not wish to receive feedback. Email address

Date raised

Topic tags/keywords