Legal Infraction Reporting

Scope

This policy applies to all Indiana University School of Medicine (IUSM) Graduate Medical Education (GME) resident physicians in ACGME-accredited and non-ACGME programs sponsored by IUSM, across all training sites and rotations.

Back to top

Policy Statement

Disclosure Requirement

Trainees must promptly report to their Program Director and the GME Office (DIO or designee) any arrest, charge, or conviction (including plea agreements and pretrial diversion agreements) that occurs during their appointment period, whether on or off duty, and regardless of location. Routine traffic violations such as parking tickets or minor speeding offenses that do not rise to the level of a misdemeanor are not required to be reported. “Promptly” means within 72 hours of the event for arrests or charges, and within seven calendar days for convictions or plea agreements, unless immediate patient or workplace safety concerns require earlier notification.

• Failure to disclose in the required timeframe may itself constitute a professionalism violation subject to corrective action.

Institutional Review

Reported infractions will be assessed by the program in partnership with the GME Office to determine fitness for duty, clinical privileges, supervision level, and any remediation, probation, summary suspension, non-reappointment, or termination actions consistent with established GME procedures.

Documentation and Confidentiality

The institution will maintain records consistent with GME record retention practices and will handle information confidentially to the extent permitted by law and policy. Disclosures may be shared with affiliated hospitals, credentialing offices, and legal authorities as necessary to ensure patient safety and compliance.

No Contractual Rights

Nothing in this policy creates contractual rights or guarantees; actions will be taken in accordance with IUSM GME policies and applicable laws.

Back to top

Reason for Policy

IUSM seeks to ensure a safe, ethical, and compliant clinical learning environment and to protect patient safety, public trust, and trainee well-being. Residents must demonstrate professionalism and personal accountability consistent with ACGME expectations and IUSM policies. Prompt disclosure of legal infractions supports appropriate risk assessment, institutional reporting duties (where applicable), and fair, consistent processes for remediation or discipline.

Additionally, IU has campus-wide obligations regarding crime reporting and workplace safety; while GME trainees are governed primarily by GME policies, each trainee is responsible for ensuring they also comply with all other applicable IU policies that require reporting, including but not limited to Clery Act Compliance and Programs Involving Children.

Back to top

Procedures

1. Trainee Reporting Steps

1. Initial Notification (within 72 hours):
   Email or call your Program Director and GME Office (DIO or designee) to report:
   1. Date/time/location of event
   2. Nature of the infraction (arrest, charge)
   3. Any immediate restrictions (e.g., driver’s license status)
   4. Pending court dates
   5. Whether patient care was implicated
2. Written Follow-up (within 7 days for conviction/plea):
   A brief written statement and any available documentation (e.g., police report number, court docket/notice) should be submitted to the program director or designee.
3. Driving-Related Infractions:
   If the event affects driving privileges (e.g., DUI/OWI), trainee must also comply with Bureau of Motor Vehicle (BMV) record check and institutional vehicle-use requirements and notify leadership of any license suspension or restrictions impacting clinical duties.
   

B. Program Director Review

1. Risk & Safety Assessment:

1. Assess patient safety, clinical role impact, supervision needs, rotation assignments, and fitness for duty.
2. Consider temporary modifications to duties or summary suspension if warranted.

2. Notification of Infraction:
   1. Promptly inform the DIO/GME Office of the infraction.
   2. Reported infractions will be assessed by the program in partnership with the GME Office to determine fitness for duty, clinical privileges, supervision level, and any remediation, probation, summary suspension, non-reappointment, or termination actions consistent with established GME procedures.
3. Professionalism/Remediation Pathway:
   1. For less severe or first-time infractions, consider Structured Improvement Plans (SIP) or probation with clear expectations.
   2. For severe infractions or repeated lapses, consider summary suspension, non‑reappointment, or termination, in coordination with the DIO and consistent with the Performance Concerns policy.
   3. Some infractions may require initiation of a fitness-for-duty assessment and professionalism review following GME procedures.
4. Institutional Obligations:
   1. When applicable, ensure compliance with IU public safety and workplace policies (e.g., reporting violent behavior; campus crime statistics obligations).
5. Documentation & Record Retention:
   1. Maintain documentation in the trainee file consistent with GME record retention standards and affiliate requirements.

C. Communication

1. Need-to-Know Basis: Share information only with stakeholders who require it (e.g., hospital credentialing, legal/risk management) to manage safety and compliance.
2. External Reporting: Trainees are advised that some infractions may require outside reporting by affiliates or may be discoverable through background checks or credentialing processes.

D. Support & Resources

Wellness and Impairment: If substance use or impairment is implicated, activate Management of Impaired Residents and Fitness for Duty processes and provide access to wellness resources.

Concerns: Trainees may seek confidential guidance via; ACGME Ombudsperson channel and formal complaint process (note: anonymous complaints to ACGME’s Office of Complaints are not accepted). https://www.acgme.org/Residents-and-Fellows/Report-an-Issue/FAQs/

Back to top

Definitions

• A resident is an IUSM resident or fellow.
• Arrest: Law enforcement taking an individual into custody so that they may be held to answer for a crime, based on probable cause or as authorized by a warrant
• Charge: Formal, written accusation, filed by a prosecuting authority, alleging an individual has violated a criminal statute
• Conviction: Formal, legal determination of guilt
• Fitness for Duty: Determination that a trainee can safely perform assigned duties based on clinical, behavioral, and regulatory considerations. (See IUSM GME Management of Fitness for Duty policy.
• Summary Suspension: Immediate temporary removal from duties pending investigation, as described in IUSM GME Performance Concerns—Structured Improvement, Probation, and Termination of Appointment.

Back to top

Implementation

The Designated Institutional Official (DIO) for GME is responsible for implementation of this policy.

Back to top

Oversight

Policy authority for this document resides with the Graduate Medical Education Committee. The DIO and the Graduate Medical Education Committee are responsible for oversight. This policy will be reviewed every three years or more often if deemed necessary. 

Back to top

History

1. gme-adm-0052, 11 March 2025, first draft of Policy.
2. Policy reviewed for content on 11 February 2026.
3. Policy approved by GMEC 25 February 2026. 

Back to top