If you have questions or would like to learn more about the BRT Committee, please review the FAQ or reach out to biasreportingtool@uw.edu
As with all emails, tools, or reports - information you share in this report may be subject to public records requests. Information shared may be subject to release under federal and state law. The BRT Committee is neither a formal investigative nor an oversight body.
The BRT is for non-emergency incidents only. FOR EMERGENCIES DIAL 911 To report criminal activity to the UW Police: Non-emergency: 206-685-8937, Anonymous Tips: 206-685-8477
Any staff, student, trainee, or faculty member of UW Medicine.
If you are a patient , contact Patient Relations by clicking here . Please do not submit a report in the BRT. If you think a patient was adversely impacted, please submit a SafetyNet report .
When you submit a report...
Please include observations and factual descriptions as much as possible. If you choose to report anonymously, please know our ability for follow up will be limited.
Date of Incident: Report opened: Days since report was filed: ______
______ ______
Label
(Ex: Anonymous, See #____, **Explicit**, No Data)
Today M-D-Y
I would like to share my name.
* must provide value
Yes No
This is a reminder that by reporting anonymously, our ability to support you is limited. We encourage you to provide your name so we can hear more about what happened and connect you to resources. If you do report anonymously, the information will be tracked for trends for potential recommendations. Thank you again for taking the time to submit a report.
View equation
Andres Barria Chantal Cayo Charisse Williams Cindy Hamra Dana Hermann Elisa Clegg Elaine Acacio Erin Alexander Gabe Sarah Gail Gray Giana Davidson Jasmine Crawford Jennifer Petritz Jessica Russell Julia Weiss Marie Westermeier Martine Pierre-Louis Nancy Colobong Smith Nola Balch Paula Houston Shawna Skjonsberg-Fotopoulos Trish Kritek HRC Not Applicable
Andres Barria Chantal Cayo Charisse Williams Chiedza Nziramasanga Cindy Hamra Dana Hermann Elisa Clegg Elaine Acacio Erin Alexander Gabe Sarah Gail Gray Giana Davidson Jasmine Crawford Jennifer Petritz Jessica Russell Julia Weiss Marie Westermeier Martine Pierre-Louis Nancy Colobong Smith Nola Balch Paula Houston Shawna Skjonsberg-Fotopoulos Trish Kritek HRC Not Applicable
The person reaching out to the reporter.
Today M-D-Y Select "Today" to automatically send the email to the reporter once the report is saved and closed.
On whose behalf are you filing this report?
* must provide value
I am filing this report on behalf of myself.
I am filing this report on behalf of someone else who is aware that I am doing so.
I am filing this report on behalf of someone else who is not aware that I am doing so.
Date of Incident
* must provide value
Today M-D-Y
UW Medicine has several locations. Where did the incident take place?
* must provide value
Please select all that apply
Please list the name of the Primary Care Clinic (PCC), if available:
System, Comm, Policy, Procedure Other
System, Comm, Policy, or Procedures:
In what type of area did the incident occur?
* must provide value
What type of bias incident occurred? Please check all that apply.
* must provide value
Type of Bias: Please specify other
What identity(s) was/ were the target of bias in this incident? Please check all that apply.
* must provide value
Ability / disability
Age
Caregiver status
Ethnicity
Gender Identity (woman, man, genderfluid, genderqueer, agender, bigender, sexism...)
Housing status
Job class / discipline (physician, nurse, medical assistant...)
Language
Race
Religion
Sexual Orientation
Size
Socioeconomic status / class
Substance Use
Transgender and/or Non-Binary (misgendering, deadnaming, cisgenderism, policy, environmental accommodation...)
Veteran status
Other
Identity: Please specify other
Please tell us what happened. We are going to ask for more detailed information about the people involved in questions to follow.
Important : Please do not include patient identifiable information (name, date of birth, medical record number).
* must provide value
Could you please help us understand a bit more about the person who was involved?
This person is an employee, trainee, student, or faculty of UW Medicine.
This person is a patient, caregiver, or visitor.
Patient
Caregiver
Visitor
How was the person involved in the event?
Affected by behavior: This person was affected by the incident.
Secondarily impacted by bias behavior: This person might feel the affects of the incident indirectly.
Engaged in bias behavior: This person was said to have engaged in a bias way.
Witnessed: This person may have observed the incident.
Unsure: This means I believe this person was involved but I am unsure their role in the incident.
SafetyNet report.
First Name: Last Name: Leave blank if unknown
Leave blank if unknown
Leave blank if unknown
How was the person involved in the event?
Affected by behavior: This person was affected by the incident.
Secondarily impacted by bias behavior: This person might feel the affects of the incident indirectly.
Engaged in bias behavior: This person was said to have engaged in a bias way.
Witnessed: This person may have observed the incident.
Unsure: This means I believe this person was involved but I am unsure their role in the incident.
Please share any additional information about the person's role.
Please click on the roles to see more options. If you do not see the role listed, please select "Other"
Academic Research and Learning Environment
Clinical Care Team Member:
Would you like to add another entry?
Yes (Entry 2 of 4)
No
Could you please help us understand a bit more about the person who was involved?
This person is an employee, trainee, student, or faculty of UW Medicine.
This person is a patient, caregiver, or visitor.
Patient
Caregiver
Visitor
How was this person involved in the event?
Affected by behavior: This person was affected by the incident.
Secondarily impacted by bias behavior: This person might feel the affects of the incident indirectly.
Engaged in bias behavior: This person was said to have engaged in a bias way.
Witnessed: This person may have observed the incident.
Unsure: This means I believe this person was involved but I am unsure their role in the incident.
SafetyNe t report.
First Name: Last Name: Leave blank if unknown
Leave blank if unknown
Leave blank if unknown
How was this person involved in the event?
Affected by behavior: This person was affected by the incident.
Secondarily impacted by bias behavior: This person might feel the affects of the incident indirectly.
Engaged in bias behavior: This person was said to have engaged in a bias way.
Witnessed: This person may have observed the incident.
Unsure: This means I believe this person was involved but I am unsure their role in the incident.
Please share any additional information about the person's role.
Please click on the roles to see more options. If you do not see the role listed, please select "Other"
Academic Research and Learning Environment
Clinical Care Team Member:
Would you like to add another entry?
Yes (Entry 3 of 4)
No
Could you please help us understand a bit more about the person who was involved?
This person is an employee, trainee, student, or faculty of UW Medicine.
This person is a patient, caregiver, or visitor
Patient
Caregiver
Visitor
How was this person involved in the event?
Affected by behavior: This person was affected by the incident.
Secondarily impacted by bias behavior: This person might feel the affects of the incident indirectly.
Engaged in bias behavior: This person was said to have engaged in a bias way.
Witnessed: This person may have observed the incident.
Unsure: This means I believe this person was involved but I am unsure their role in the incident.
SafetyNet report.
First Name: Last Name: Leave blank if unknown
Leave blank if unknown
Leave blank if unknown
How was this person involved in the event?
Affected by behavior: This person was affected by the incident.
Secondarily impacted by bias behavior: This person might feel the affects of the incident indirectly.
Engaged in bias behavior: This person was said to have engaged in a bias way.
Witnessed: This person may have observed the incident.
Unsure: This means I believe this person was involved but I am unsure their role in the incident.
Please share any additional information about the person's role.
Please click on the roles to see more options. If you do not see the role listed, please select "Other"
Academic Research and Learning Environment
Clinical Care Team Member:
Would you like to add another entry?
Yes (Entry 4 of 4)
No
Could you please help us understand a bit more about the person who was involved?
This person is an employee, trainee, student, or faculty of UW Medicine.
This person is a patient, caregiver, or visitor.
Patient
Caregiver
Visitor
How was this person involved in the event?
Affected by behavior: This person was affected by the incident.
Secondarily impacted by bias behavior: This person might feel the affects of the incident indirectly.
Engaged in bias behavior: This person was said to have engaged in a bias way.
Witnessed: This person may have observed the incident.
Unsure: This means I believe this person was involved but I am unsure their role in the incident.
SafetyNet report.
First Name: Last Name: Leave blank if unknown
Leave blank if unknown
Leave blank if unknown
How was this person involved in the event?
Affected by behavior: This person was affected by the incident.
Secondarily impacted by bias behavior: This person might feel the affects of the incident indirectly.
Engaged in bias behavior: This person was said to have engaged in a bias way.
Witnessed: This person may have observed the incident.
Unsure: This means I believe this person was involved but I am unsure their role in the incident.
Please share any additional information about the person's role.
Please click on the roles to see more options. If you do not see the role listed, please select "Other"
Academic Research and Learning Environment
Clinical Care Team Member:
Please attach any supporting documents or materials here:
Today M-D-Y
Call Notes For more support, view the Contact Script
*How are you?
*Additional notes?
*Spoken with colleagues / manager?
*SafetyNet Report? *Care team aware / checked in with patient? *If patient expressed concerns, connected with patient relations?
*What are your hopes with reporting this information? Not investigative committee, but something we like to understand from everyone who reports.
*Ok for us to contact you again if questions come up?
*Questions for me or our team?
View equation Days between open and closed
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Today M-D-Y
Date of Incident: Report opened: Days between open and close: ______
______ ______