College of MedicineMD ProgramStudent AffairsWSU College of Medicine Forms

WSU College of Medicine Forms

To request an approved absence, please log into E.Flo. Open your Profile Menu, select Absences, and follow the prompts to request your absence.

For step-by-step instructions visit the MedTech website.

Student mistreatment involving discrimination, sexual harassment or sexual mistreatment can be reported directly to Office of Compliance and Civil Rights, by calling 509-335-8288, or by emailing ccr@wsu.edu. All reports of student mistreatment received by the WSU College of Medicine will be routed to the Office of Admissions and Student Affairs. Upon the receipt of a mistreatment report, the Assisstant Dean of Student Affairs promptly reviews the report. If you are unsure about what to do, you can contact the College of Medicine Office of Admissions and Student Affairs at medicine.studentaffairs@wsu.edu or by calling 509-368-6827.

Reporting may be done anonymously. Anonymous submissions are inherently more difficult to investigate. Whenever possible, we encourage the report to include the name of the individual submitting the form.

Learner Mistreatment Complaint Form

I have read the definition of mistreatment posted in the student handbook website.(Required)
Having read the definition of student mistreatment, I believe a student suffered mistreatment.(Required)
Please select the best descriptor of the inappropriate behavior (choose all that apply).(Required)
The individual I hold responsible for this behavior is:(Required)

Your Name

Use this form to report a co-curricular concern about a student.

The Elson S. Floyd College of Medicine strives to create an environment that produces future physicians who possess not only the knowledge of the most advanced scientific and clinical fundamentals, but are physicians who do so while behaving in ways that honor the profession of medicine. Helping our students achieve this level of professionalism is as important to our medical school as is its success in educating students in the biological and clinical sciences. To support students as they develop competency in the domain of professionalism, the WSU College of Medicine has developed a central system, within the Assessment Unit, to track and communicate issues related to professionalism. This central tracking process ensures that all relevant information is available to help the program identify students who exhibit patterns of behavior that may require remediation and/or other types of support.

MD Program Office of Student Affairs Co-Curricular Concern Card

Campus
Best descriptor of behavior(s) (select all that apply)(Required)
Name of student you are raising concerns about:(Required)
Your Name(Required)

Use this form to provide emergency contact information.

The Office of Student Affairs is collecting information in the event a student encounters a personal emergency or there is a general emergency on campus.

This form is to be completed on an annual basis, two weeks prior to the start of classes and at the time of any changes to the information contained herein.

This data will be kept confidential and will only be used by the Office of Student Affairs for this reason.

Student Emergency Contact Form

Your Information

Name(Required)
Preferred Pronouns:

Local Address(Required)

Emergency Contact

Name

Secondary Emergency Contact

Name

Process

All emergency fund requests are entered through a single WSU form online.

If emergency funds are not available from WSU Pullman or the WSU Spokane campus, the request will be forwarded to the College of Medicine. The college has the following purpose and process.

Purpose

The Emergency Fund provides emergency financial support of up to $1,000 per individual request to Elson S. Floyd College of Medicine medical students. Funds are awarded based on:

  1. Hardship: Students must demonstrate an unexpected hardship.
  2. Limited Financial Resources: Students must demonstrate that they have no or few viable options for other sources of funds.

More than $1,000 may be considered depending on the emergency.

Review Policy

  • Please submit your request as soon as possible for review.
  • It may take up to 5 business days to review and process the request before access to emergency funds can be provided.
  • Documents that support the request for funds may be required (invoices, etc.).
  • A review committee comprised of the College’s executive leadership will be responsible for accepting and reviewing applications.
  • If funds are awarded, the student agrees to write a thank you letter to the donor.
  • If additional information is needed, the student affairs staff will contact you.

Emergency Fund Application

Please complete the Student Emergency Funding Request form here.

Emergency Fund Request Application

Use this form to provide feedback so the College of Medicine can continue to improve the medical school experience.

As co-partners in the Elson S. Floyd College of Medicine, we greatly value feedback from our students to ensure continued improvement in the medical school experience.

If you would like to share feedback anonymously, please complete the form below to share feedback on the operations of the College of Medicine, such as curriculum, student affairs, administration, etc. You may also submit feedback via email at medicine.evaluation@wsu.edu, but please note that if you use this email address, it will not be anonymous.

Student Feedback

This form is for those providing health services for medical students.

When a situation is discovered where a student receives health services, including psychiatric/psychological services, by a provider who is also involved in the student’s academic assessment, it must be reported to the Associate Dean of Accreditation, Assessment and Evaluation. Please be mindful of confidentiality issues in completing this form.

Upon submission of this form, the information will be sent to the Associate Dean of Accreditation, Assessment and Evaluation. Make sure you are familiar with the Non-Involvement of Providers of Student Health Services in Assessment Policy 

Health Provider Involvement in Student Assessment

I have read the Non-Involvement of Providers of Student Health Services in Assessment Policy.
Your name:

This form is used for students who need reasonable accommodations for religious observances and practices.

Request for Reasonable Accommodations for Religious Observances

MM slash DD slash YYYY
Name
Year in Program
Assigned Learning Community

Use this form if you’d like to use the VCC for a workshop.

This form will be sent to the Director of Simulation-Based Training. You will be contacted by a representative of the Virtual Clinical Center within one business day regarding initial approval of your request. After initial approval is granted, you will need to obtain signatures from the curriculum office and student services to proceed. When all three signatures (Initial approval, curriculum office, and student services are obtained, this completed form needs to be returned to the Virtual Clinical Center for FINAL approval. Once final approval is granted, the VCC staff and faculty will work with you to finalize your workshop. This will include VCC room reservation, borrowing of equipment, and providing a source for consumables to be purchased. A copy of this form will be provided to workshop organizers.

Virtual Clinical Center (VCC) Workshop Request

Name(Required)
Is this for a Special Interest Group?(Required)
Is this workshop open to ALL students?(Required)
Are there any guest speakers leading the workshop?(Required)
Are there any possible financial costs associated with this workshop?(Required)
Possible costs can include food, supplies (suture material, gloves, gowns), or other consumable items. Partial task trainers and other durable goods are available at no cost pending their availability. Associated costs are the responsibility of the organizing group.
If the workshop is at the VCC, is it scheduled outside of VCC operating hours (M-F 8 a.m. – 5 p.m.)?