Chapter VI: Institutional Policies

The policies relating to the relationships faculty members may have with business organizations, the government or other institutions are set forth in various policies contained in this Handbook, specifically, the policies regarding the use of the Mount Sinai name, the policy regarding consultative arrangements the restrictions on the activities of full-time faculty, the conflict of interest policy, and the policies on intellectual property. Nonetheless, in the event a faculty member has any concern about whether a particular proposed arrangement is appropriate or acceptable, the faculty member should consult the Dean's Office.

Updated August 2017

In conformity with the principles of academic freedom, faculty members are not required to obtain prior approval before submitting a manuscript for publication or to amend such manuscripts to comply with suggestions made by others. However, it is recommended that faculty members provide Department Chairs with copies of manuscripts prior to publication.

All original laboratory data in any format from which a publication is derived must be stored in the laboratory for a minimum of six years from the date of publication. If the senior author leaves Icahn School of Medicine before the six year period elapses, he/she will be required to retain or maintain and make available, if requested, to Icahn School of Medicine all these data until the completion of this minimum time period. In the case of large ongoing database related research, the responsible investigator must, if the data are stored on a specific device, retain the pertinent mass data storage device (tape, disk, etc., not necessarily in hard copy) containing the data on which a publication is based or maintain these data. Any stored or maintained data can be used for verification, as well as serve as the base for ongoing studies of the same project. In the latter instance, however, a clarifying statement which describes the nature and the composition of the reutilized and incremental data should accompany the publication. For cases in which a separate device is used, it cannot be reused for unrelated projects. Although it is understood that this rule governing database storage may not be appropriate in all situations and over time, individual modifications must be approved by the Dean or his designee.

Updated August 2017

The School of Medicine strongly believes in the importance of protecting whistleblowers from retaliation and addressing good faith allegations of such retaliation. Accordingly, the School affirms that it will adhere to any applicable policies and procedures promulgated by federal or other oversight agencies in dealing with such allegations. Whistleblower complaints of retaliation may be brought, where appropriate, to the School’s Faculty Council (see Chapter II), Grievance Committee (see Chapter II), or Department of Human Resources.

Copies of the policies and procedures of the Grievance Committee are available from the Office of the Dean, Reserve Section of the Levy Library, House Staff Affairs Office, Postdoctoral Affairs Office, Office of the Graduate School, and Office of Student Affairs. Human Resources policies are available from the Department of Human Resources.



The Icahn School of Medicine at Mount Sinai (ISMMS) is dedicated to providing its students, postdocs, residents, faculty, staff and patients with an environment of respect, dignity, inclusion, trust, support, and protection of civil and professional discourse, free of mistreatment, abuse, or coercion, and without fear of retaliation.

Educators (defined broadly to include anyone in a teaching or mentoring role, including faculty, postdocs, residents, fellows, nurses, staff, and students) bear significant responsibility in creating and maintaining this environment. As role models and evaluators, educators must practice appropriate professional behavior toward, and in the presence of, students and trainees, who are in a particularly vulnerable position due to the formative and dependent nature of their status.

These guidelines supplement the institutional policies on harassment, grievances and sexual misconduct; will assist in developing and maintaining optimal learning environments; and encourage educators, students and trainees alike to accept their responsibilities as representatives of the ISMMS in their interactions with their colleagues, patients, and staff.

Mistreatment interferes with the learning environment, adversely impacts well-being and the trainee-mentor relationship, and has the potential for negatively impacting patient care and research. Inappropriate and unacceptable behaviors promote an atmosphere in which mistreatment is accepted and perpetuated in medical and graduate education.

Everyone at the ISMMS deserves to experience a professional learning and working environment. This policy focuses on the mistreatment of students and trainees.

While individuals might perceive behaviors differently, examples of mistreatment include, but are not limited to being:

  • Publicly embarrassed or humiliated
  • Threatened with physical harm or physically harmed
  • Required to perform personal services
  • Subjected to offensive remarks related to gender, sexual orientation, nationality, race or ethnicity
  • Denied opportunities for training or rewards based upon gender, sexual orientation, nationality, race or ethnicity
  • Subjected to lower evaluations or grades solely because of gender, sexual orientation, nationality, race or ethnicity
  • Subjected to unwanted sexual advances
  • Asked to exchange sexual favors for grades or other rewards
  • Subjected to the threat of revoking visa status for foreign nationals


ISMMS has a zero tolerance policy towards mistreatment. Zero tolerance means that all reported incidents are scrutinized and result in an action plan. Although egregious or persistent mistreatment may require disciplinary action, we recognize in episodes of mistreatment an opportunity to develop, improve, and remediate unprofessional behaviors that detract from a learning and working environment we can all be proud of.

This mistreatment policy is closely aligned with our institution’s Cultural Transformation efforts, the medical school’s Racism and Bias Initiative, and related policies.

Reporting Mechanisms

All reports (except those received by the Ombuds Office, which are strictly confidential) will be reviewed in real-time by the respective office that oversees the Graduate School UME, GME, or Post-Doctoral Affairs. Reports of mistreatment that are egregious or part of a worrisome trend will be reported to the Mistreatment Committee immediately for adjudication. All other reports will be reviewed by the Mistreatment Committee quarterly.

  • Students
    • Course evaluations: course evaluations provide an opportunity for students to anonymously reports incidents of mistreatment. Students may also choose to speak to Course Directors directly about concerns related to mistreatment. Course Directors can offer recommendations or refer as appropriate.
    • Clerkship evaluations: Students evaluate faculty and residents with whom they have worked through end-of clerkship evaluations. The reporting mechanism reminds students that their report is anonymous, asks who the individuals involved were, the type of mistreatment, additional details, and if the student reported the incident during their rotation. The Senior Associate Deans of Student Affairs and Curricular Affairs review these data quarterly. They aggregate and share the data with each clerkship director. Additionally, the Mistreatment Resource Panel reviews these data at each meeting. Clerkship evaluations are anonymous for the complainant and the data will be aggregated and de-identified when reviewed.
    • Clerkship Director(s): Medical students in Year 3 or Year 4 are encouraged to speak with their Clerkship Directors directly. Clerkship Directors will investigate as appropriate and submit a report to the Senior Associate Deans for Undergraduate Medical Education on a regular basis summarizing cases and outcomes. When possible, student identity will be withheld in such reports to ensure anonymity of students submitting a complaint.
    • Faculty Advisors and Deans: Students can report concerns to any of their instructors, Faculty Advisors, mentors or Deans. Each serves as a student advocate and will provide recommendations or refer as appropriate.
    • Mistreatment Resource Panel: Students may report mistreatment directly to the Mistreatment Resource Panel by emailing (medical students) or (graduate students), or contacting their class representative directly. The panel will meet to discuss the case with the reporting student’s information de-identified and next steps will be communicated as appropriate. For more information about this panel, please see next section.
    • Office of the Ombuds ( The Ombuds Office provides neutral, confidential, and informal assistance in conflict resolution. The Ombuds Office follows best standards of practice that are necessary to promote fair and equitable outcomes.
    • Office of Human Resources
    • Compliance Hotline and real-time reporting


  • Residents
    • The Graduate Medical Education (GME) Office will review any negative evaluation of a faculty by a resident or fellow.  They will review prior evaluations to determine if a pattern of mistreatment exists.  The GME Office will batch such evaluations over a minimum of 6 months or 4 evaluations and review them with the Chair or Program Director to maintain anonymity. 
    • Regular resident evaluations of faculty in New Innovations (the GME Office batches these evaluations with no less than 3 others to protect the anonymity of the trainee).  Responses to specific questions about mistreatment or negative evaluations are reported directly to the GME Office. 
    • Web-based real-time reporting of anonymous concerns on the GME Website allow for a resident or fellow to make an anonymous complaint of mistreatment and are handled immediately. 
    • Program Directors and teaching faculty may receive reports of concerns and are encouraged to appropriately handle or report these to the Chair or Program Director.
    • Faculty Advisors provide ongoing support and career advice to residents and fellows
    • Chief Residents are provided training on how to handle reports and concerns about mistreatment
    • Ombudspersons for GME are appointed for each of the clinical campuses and offer a safe and confidential place to discuss training related issues and concerns. The Ombuds Office ( provides neutral, confidential, and informal assistance in conflict resolution. The Ombuds Office follows best standards of practice that are necessary to promote fair and equitable outcomes.
    • Office of Human Resources
    • Compliance hotline – a telephone hotline has been set up to handle phone calls about concerns of mistreatment (800-853-9212)
    • Mistreatment Resource Panel by emailing The panel will meet to discuss the case with the reporting trainee’s information de-identified and next steps will be communicated as appropriate. For more information about this panel, please see next section.
    • Office of the Ombuds ( The Ombudspersons offer a safe and confidential place to discuss campus-related personal and professional issues and concerns. They strive to resolve conflicts to the mutual satisfaction of all parties, and can provide information, shuttle diplomacy, or refer to other resources as appropriate. 
    • Office of Human Resources
    • Compliance hotline – a telephone hotline has been set up to handle phone calls about concerns of mistreatment (800-853-9212)
  • Post-doctoral Fellows
    • Faculty Director, Office of Postdoctoral Affairs
    • Program Manager, Office of postdoctoral Affairs
    • Senior Associate Dean for Student Affairs, Graduate School
    • Head of lab or your direct supervisor in lab
    • Department Chair


A Mistreatment Committee overseeing medical school, graduate school, GME, and post-doctoral mistreatment will meet quarterly. The committee membership includes the Dean for GME, Dean for Medical Education, Dean of the Graduate School of Biomedical Sciences, Dean for Diversity Affairs, CWO, Dean for Women’s Equity, Chair of the Physician’s Wellness Committee, MSH CMO, representative from Human Resources, student reps, postdoctoral fellow representatives, and housestaff representatives.

This committee will review all reports of mistreatment and cross-reference them across historical reports from the Graduate School, Undergraduate Medical Education (UME), Graduate Medical Education (GME), and School Human REsources.

An ad hoc sub-committee will meet to review any report of mistreatment that is felt to be egregious and may require an immediate response.  This ad hoc committee will also undertake formal investigation of the mistreatment when appropriate, and report its findings to the full committee.

The committee’s determinations will fall into one of three categories:

  • Not mistreatment: no response needed, internal file for future reference
  • Mistreatment: Graded response below
  • Egregious mistreatment potentially requiring discipline: formal investigation

If the mistreating party is not named, the report will be forwarded to the Chair of the relevant department and the Dean. The Chair will collaborate with the Dean for UME and/or Dean of the Graduate School and/or Dean for GME on improvements to the learning environment (may include special grand rounds, consultation with the CWO, Physician Wellness Committee, Employee Health Service, leadership of ODI, Dean for Women’s Equity)

Graded Response Policy

We recognize that mistreatment can range from a single, first-time episode that is not egregious, to persistent low-grade mistreating behavior, to single incidents so egregious that they require disciplinary action. Below is the range of possible responses, each of which will be tailored to the circumstances of the mistreatment.

  • Monitoring the behavior of the person accused of mistreatment
  • Mandatory meeting with a member of the Mistreatment Committee
  • Formal letter to Chair and Dean of the School of Medicine, mandatory meeting with the Chair
  • Formal letter to Chair and Dean of the School of Medicine, mandatory meeting with the Chair as well as the Dean for UME and/or Dean of the Graduate School and/or Dean for GME, and/or the CMO. May or may not require referral to the Physician Wellness Committee, Employee Health Service, or Student-Trainee Mental Health
  • Egregious mistreatment or a pattern of mistreatment despite remediation may result in disciplinary action, up to and including dismissal.

Closing the loop

Quarterly reports sent to students, residents, postdoctoral fellows, the Dean, all chairs, CMOs, and hospital presidents, head of Nursing, head of Social Work.

ACGME and GQ data shared with students, residents, postdoctoral fellows, the Dean, all chairs, CMOs, and hospital presidents, head of Nursing, head of Social Work.

Complainant report-back meeting with a representative of the Mistreatment Committee if the complainant’s identity is known.

Protection from Retaliation

Retaliation (including but not limited to adverse effects on student evaluation) against individuals who bring forward complaints of mistreatment or participate in investigations of complaints of mistreatment is strictly prohibited and will not be tolerated. Concerns about retaliation should be reported to the ‘mistreatment committee’ for investigation.


New Policy Posted April 2019

It is the policy of the Icahn School of Medicine that all decisions regarding educational and employment opportunities and performance are made on the basis of merit and without discrimination because of race, sex, color, creed, age, national origin, handicap, veteran status, marital status, or sexual orientation. In keeping with its efforts to achieve a broad representation of women and minority groups throughout the institution, Icahn School of Medicine has an Affirmative Action Program. This Program is designed to realize the School's commitment to equal educational and employment opportunities, to achieve compliance with federal, state, and local laws and regulations, and to implement equal opportunity objectives by meeting the spirit as well as the letter of the law and contractual requirements.

Oath of Allegiance

The New York State Education Law requires citizens of the United States who are faculty members of educational institutions to take an oath to support the Federal and State Constitutions. The oath which Mount Sinai Faculty are asked to sign as a condition for appointment, is as follows:

"I do hereby pledge and declare that I will support the Constitution of the United States of America and the Constitution of the State of New York, and that I will faithfully discharge my duties as a member of the faculty of the Icahn School of Medicine at Mount Sinai according to the best of my ability."


Faculty of the School of Medicine whose professional activity includes patient care in the Mount Sinai Hospital or affiliated institutions must be licensed as physicians by the State of New York.

Immigration Status

Every faculty member who is not a United States citizen must provide evidence that he/she is permitted by Federal law to work in the capacity for which he/she is hired. Further, compliance with the Immigration Control and Reform Act requires that all newly hired faculty who are not United States citizens must also complete an I-9 form and provide the necessary identification to comply with the law.

Pre-employment Toxicology Screening and Physical Examination

All newly hired faculty must consent to pre-employment toxicology screening and a complete physical examination.

Security Check

All newly hired faculty must consent to a security check.

Icahn School of Medicine is committed to lawful and ethical behavior in all of its activities and requires all staff and employees to conduct themselves in a manner that complies with all applicable laws and regulations. Every employee and staff member of Mount Sinai should be aware of the legal and ethical requirements governing the performance of his or her employment responsibilities or other relationship to Mount Sinai. Mount Sinai has established a compliance program for maintaining and ensuring fidelity to those standards of conduct required of all employees and staff members. This program includes the establishment of written policies setting forth standards of conduct and the establishment of a "hotline" for the reporting of illegal or unethical behavior. In addition, a chief compliance officer has been appointed with responsibility for implementing the compliance program. Information concerning the compliance program will periodically be sent to employees and staff and is also available directly from the compliance officer.

Mount Sinai maintains a vigorous compliance program and strives to educate its work force on fraud and abuse laws, including the importance of submitting accurate claims and reports to the Federal and State governments. It is expected that employees who are aware of any occurrences of fraud, waste and/or abuse report their concerns directly through the Compliance Helpline at (800) 853-9212. There shall be no reprisals for good faith reporting of actual or possible incidence.

Mount Sinai has adopted an extensive set of programs in the Health System for detecting and preventing fraud, waste, and abuse. The Compliance Department oversees these programs and depending on the nature of the allegations, works collaboratively with the Audit Services Department and the Office of the General Counsel to conduct investigations in these areas. Periodically, please check Mount Sinai's Policies and Procedures for Detecting and Preventing Fraud and Abuse to keep current with the latest regulatory changes.

The Mount Sinai Health System is committed to ensuring the safety and well-being of all persons on Health System property or engaged in Health System activities. Recognized hazards that could cause injury or illness to faculty, staff, students, patients, or visitors are controlled and monitored. Appropriate oversight also protects Health System facilities from risk of damage from unsafe acts or conditions.

All members of the Mount Sinai Health System community, including all faculty, are expected to share this concern for workplace safety and are required to participate in institutional efforts to encourage safety and control risk in all activities. It is each person’s responsibility to be alert to actual or potential hazards and to take appropriate steps to control them.

Research and clinical laboratories present particular concerns for safety. Faculty engaged in laboratory instruction or research are obligated to assure compliance with applicable safety protocols and regulations in their laboratories.

Faculty and staff who fail to comply with internal policies and external regulatory requirements will be subject to disciplinary action up to and including dismissal.

The Office of Environmental Health and Safety (; 212-241-7233) is available to consult with faculty and staff on all safety-related questions, policies and procedures. Any safety issue, concern or question can be directed to this office. Inquiries can be treated confidentially.

Updated June 2015

Icahn School of Medicine and each member hospital in the Mount Sinai Health System Emergency have in place emergency response procedures, with responsibility for activities assigned to pre-designated individuals as needed. For School faculty, emergency response assignments originate with the Chairperson of the faculty members' primary appointment.

In accordance with the requirements of the Education Law of the State of New York, the Trustees of Icahn School of Medicine at Mount Sinai has adopted rules for the maintenance of order in the School and have established a program for their enforcement. Learn Campus Rules and Regulations.