Discrimination/Harassment Complaint Form
University of South Carolina • Office of Equal Opportunity Programs/1600 Hampton Street, Suite 805, Columbia, SC 29208
(Ph) (803) 777-3854 (Fax) (803) 777-2296
To file a complaint, complete and return this form to Office of Equal Opportunity Programs.
This form may be faxed (803) 777-2296, emailed (wellscr@mailbox.sc.edu), or mailed to the
Office of Equal Opportunity Programs @ 1600 Hampton Street, Suite 805, Columbia, SC 29208 (803) 777-3854
Name ______________________________________________________________________________________________________
Address ____________________________________________________________________________________________________
City State Zip Code ___________________________________________________________________________________________
Home Telephone __________________________________________ Business Telephone __________________________________
Department _______________________________________________________________________________________________
Nature of discrimination/harassment:_______ Age
_______ National origin
_______ Sexual harassment
________ Color
_______ Genetics
_______ Sexual orientation
________Disability
_______ Race
_______ Veteran’s status
________Gender
_______Religion
Date of Alleged discrimination __________________________________________________________________________________
Department/individual whom you believe has discriminated against you _________________________________________________
May we contact department/individual?
______ Yes ______ No
Describe alleged incident (use additional sheets if necessary) __________________________________________________________
___________________________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Remedy requested __________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
The information provided above is true and correct to the best of my knowledge.
______________________________________________________
Signature
_________________________________
Date
The Office of Equal Opportunity Programs will contact you in a timely manner.