University of Minnesota Medical School DEI Coaching Share Form
Fill out this form if you are interested in meeting with a DEI Coach (Bios). DEI Coaches are physicians with diverse identities and backgrounds brought together to support U of MN medical students. You may fill this form in another's person's behalf.  All questions are optional but it allows us to better understand your needs and then to match you with a DEI Coach. 

Here are some examples of reasons why you might want to meet with a DEI coach, particularly it involves your identity or background:
  • I want support to build community around my identity or background
  • I am interested in a specialty but none of the physicians look like me
  • I want to give feedback about curriculum or rotations related to DEI or about DEI Coaches
  • I want to share a positive example of someone who demonstrated excellence in DEI work
  • I want advice to navigate my rotation
  • I witnessed or was part of mistreatment
  • I am thinking about making a formal report but I am not sure
We will need your name for documentation and follow up purposes. This info will only be shared with the DEI Co-Directors Cuong Pham, MD (pham0079@umn.edu) and Viviane Leuche, MD (tchon002@umn.edu), as well as your matched coach.

Please note the following:
  • In compliance with the University of Minnesota Title IX policy, the DEI coaches are mandatory reporters for sexual mistreatment. For additional info: https://eoaa.umn.edu/report-misconduct
  • Privacy Statement:  Based on federal and state laws, any information regarding experiences in the learning environment or your health care data are considered private and will not be shared outside of your meeting with the DEI Coaching program.
  • This is NOT an official reporting tool. If you wish to report an incident, refer to this link or we may help you through this process. 
Other Resources:
  • Aurora Center is to serve all victims/survivors/concerned people of sexual assault, relationship violence, stalking, and sexual harassment at the University of Minnesota and Augsburg University.
  • Confidential Bridging is free and confidential short term in-house counseling service that can serve as a “bridge” of support
  • Student Conflict Resolution Center is University wide service to assist students in resolving campus-based problems or concerns
  • Learner Development  provides a range of service and resource options to support student & trainee performance, wellbeing and mental health across the UME and GME years.
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Email *
Your name  *
(Optional)  Name you preferred to be called by and preferred pronouns 
What would you like to discuss during your meeting with the DEI Coach? Note that if issue fits under mandatory reporting, it would have to be reported. If you would prefer to reach out to non-mandatory reporters, please see above. *
Required
Preferred Contact Info (Phone/Email) *
In general, what days and time  are best to meet in the next couple weeks? *
(Optional) If you want us know, please share anything important about your identity and/or background.
(Optional)  Describe in as much detail as you wish what you would like to discuss with the Coach. 
 (Optional)  If applicable, what steps have you already taken? 
(Optional)   If applicable, what do you hope or expect to get out of meeting with a Coach?
Which DEI Coach(es) would you like to me meet with?  Choose as many as you wish or none.  We will try our best to accommodate your wishes.  (Bios)   *
Required
(Optional)  If you want us to choose your Coach, do you have a preference in the Coach's identity or background? (Bios)  
(Optional)  Other Comments or Feedback
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