Medical University of South Carolina
Equal Employment Opportunity/Affirmative Action Office
20 Erhardt Street - Unit #2
Charleston, SC 29424
(843)792-1568/1282

Harassment Discrimination Complaint Form


1. PERSON(S) INVOLVED Please list the person who is directing this harassment towards you.


NAME______________________________________ OFFICE/ROOM__________________________

________________________________________________________________________________

DEPARTMENT________________________________ TELEPHONE____________________________

Age____________ Ethnicity___________________ Gender__________

Are there others involved in this harassment towards you? Yes _____ No_____
if yes, please fill out a form for each additional person.
What position does this person hold on campus? _________________________________

 

 

_________________________________________________________________________________
 

2. LOCATION
Where did the incident(s) occur ? ___________________________________________

 

 

_________________________________________________________________________________
 
 

3. TIME
When did the incident(s) occur ? (Times and dates)_______________________________

 

 

_________________________________________________________________________________
 
 

4. DESCRIPTION: Please describe the incident(s) and include such information
as how you were harassed; if the harassment included body contact and to what
extent; what if any, gestures or language were used; and if there were any
witnesses to the incident(s).Indicate if there were any threats or promises
in connection with the harassment. Please use as much space as necessary.

 

 

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

5. Have you discussed this situation with the person involved?

Yes_____ No_____ If no,
why not? If yes, what was the response ? Please list date, time
and location of this discussion.____________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

6. Have you discussed this situation with the person's supervisor?

Yes___ No___ If no,
why not? If yes, what was the persons response? Please list date, time
and location of this discussion. __________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

7. Have you discussed this situation with your supervisor or the appropriate
MUSC  administrator? Yes___ No____. If no, why not?
If yes, what was the persons response?
Please list date, time and location of this discussion. _____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________
 

8. What corrective action would like to see taken regarding this matter?

____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________
 

9. Please list any additional information which you feel would be helpful to the
University in investigating your complaint. _________________________________

_____________________________________________________________________________

_____________________________________________________________________________

The above summation of my complaint is accurate to the best of my knowledge.

NAME OF PERSON MAKING COMPLAINT _____________________________________________________

ADDRESS/WORK LOCATION _______________________________________________________________

TELEPHONE - DAY ( )_______________________ EVENING ( )________________

SIGNATURE___________________________________ DATE_________________________

SIGNATURE OF PERSON TAKING REPORT____________________________________________________

TITLE_______________________________________________________________ DATE___________