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Home Healthcare Professionals Med Staff Well-Being Professionalism Referral

Professionalism Referral

Referral to the UCI Irvine Professionalism Committee

Complete this form in its entirety, sign and submit to the UC Irvine Well-Being Commitee.

Description of incident

Please describe the behavior observed as factually and objectively as possible, including the events, which precipitated the behavior, if known. Provide all relevant details.

Effect on patient care or hospital operations

Action taken