Advanced Practitioners and Medical Associate Professions Incivility Reporting Tool

If you are filling in this form, you have likely experienced or witnessed some form of unacceptable behaviour within the Group. By giving us as much information as you can, you will help us to support you and other Advanced Practitioners and Medical Associate Professionals. If possible, please give contact details. This means that even if you wish to remain anonymous in your complaint, we are still able to feedback any actions and offer support as needed.

We need to gather information about incidents and work on interventions that will address the problem. Our aim is to create a fairer, kinder and more inclusive place to work, so thank you for telling us. We hope this will benefit not only you as an individual, but remove rudeness and poor behaviours for all staff in the future.

The information shared will be reviewed by an independent team, called a Circle Group. They triangulate the information, deal with individual complaints and identify patterns from anonymous complaints, so that action can be taken. This group is coordinated by the HR and OD Team and will not include internal team members. If you do give us your contact details, a member of the Circle Group will contact you for more information. This is to help us understand what your expectation of a resolution would be.

Thank you for reporting; we want to make a difference to your workplace and you are helping make that happen.

Reference

Recipient Role(Required)

Advanced Clinical Practitioner

Advanced Critical Care Practitioner

Advanced Neonatal Nurse Practitioner

Anaesthesia Associate

Physician Associate

Surgical Care Practitioner

Is the recipient qualified or in-training?(Required)

Qualified

In-Training

Please describe your event or situation.(Required)

Be as specific and detailed as you can possibly be.

Whose behaviour are you reporting?(Required)

If known, please include their role and seniority.

What would you like to happen as a result of this report?(Required)

I am reporting on behalf of:(Required)

Myself

Someone else

Do you wish to remain anonymous?(Required)

Yes

If you have opted to remain anonymous your details will not be shared with anyone without your express permission. We only need your details so we can check in with you, gather further supporting information, give feedback, and offer you any support you need. This report is not shared with anyone in the service and goes directly to the circle group only.

Is this person aware that you are reporting this?(Required)

Yes

Do you wish to provide their contact details?(Required)

Yes

This will allow us to follow up with them.

Who is involved?(Required)

A member of staff

A service user

Other

Please select all that apply.

As you selected Other, please specify.(Required)

Protected characteristics

Collecting this type of data helps us to see which groups of staff are most frequently subject to discrimination, bullying and harassment, and acts of aggression and violence. It also helps us to recognise which staff might not be reporting such incidents. It enables us to work with those staff to understand how we can support them in the future.

Do you have a disability?

Yes

What is your ethnicity?

What is your sexual orientation?

What is your gender?

Details of the event

Where did the event take place?(Required)

My usual work area

An area of the trust I was visiting to carry out work

Elsewhere on trust property

Other

Please specify where exactly.(Required)

Are you relying on your keyboard or a screen reader to complete this form?(Required)

Yes

What was the date of the event?(Required)

What was the date of the event? (ACCESSIBLE)(Required)

What was the time of the event?(Required)

Who witnessed the event and/or was affected by it?(Required)

Please give specific names and identifiable information. What was the impact on bystanders and the wider team?

Hidden

Who were the affected people during the event?(Required)

For example, what was the impact on bystanders and the wider team?

Do you require immediate contact or support?(Required)

Yes

Does the recipient require immediate contact or support?(Required)

Yes

You've said the recipient needs immediate contact or support, but you've also opted not to provide their contact details. How should we support them?(Required)

Which of the following would describe the situation?(Required)

Select all that apply.

As you selected "Other", please specify.(Required)

Is this a pattern of behaviour?(Required)

Yes

Have you already raised concerns with anyone?(Required)

Yes

Is your Educational or Clinical Supervisor aware of this issue?(Required)

Yes

I do not have an assigned Educational or Clinical Supervisor

Who?(Required)

What steps have you taken so far to address your concerns?(Required)

What actions have been taken so far, and by whom?(Required)

Were you satisfied with how it was handled?(Required)

Yes

My Contact Details

My Name(Required)

Forename Surname

My Email Address(Required)

My Job Title(Required)

My Department(Required)

My Health Group or Directorate(Required)

Their Contact Details

Their Name(Required)

Forename Surname

Their Email Address(Required)

Their Job Title(Required)

Their Department(Required)

Their Health Group or Directorate(Required)

This field is for validation purposes and should be left unchanged.