Date:
Student Name:
Faculty Name:
Location/Context:
Chicago Medical School
Rosalind Franklin University
Report of Exemplary Professional Behavior
Dear Dean Reifler:
This student has demonstrated exemplary professional behavior in one or more of the following realms
(please circle all that apply):
Personal accountability: Punctuality, Initiative, Dependability, Grooming/Hygiene, Dress, Responsiveness
to Instructions and Policies, Responsiveness to Feedback, Striving for Excellence
Demeanor: Humility, Altruism, Compassion, Self-Awareness, Adaptability, Composure
Ethical behavior: Honesty, Integrity, Fairness, Confidentiality, Informed Consent
Relations with others: Respect, Verbal Communication, Nonverbal Communication, Cultural Awareness,
Cultural Acceptance
Relations with the community: Teamwork, Community Service, Stewardship, Advocacy
Other (please specify):
I am referring to the following specific behavior(s):
Sincerely,
________________________
Faculty Signature
I have discussed this report with the faculty member. Comments (optional):
________________________
Student Signature