COLLEGE OF MEDICINE

Report Student Mistreatment, Learning Environment and/or Other Concerns

Anonymous Reporting: Students, faculty, fellows, residents, and staff may report an incident using this form without disclosing identifying information (i.e., name, email and phone number fields are optional). Reports submitted in an anonymous manner may limit the ability of the College to investigate and address the incident. However, all reports will be reviewed and efforts will be made to address the incident. In addition, anonymous reports can help us identify any patterns of mistreatment that may be occurring in a particular department, unit or site, allowing us to address the behaviors and increase prevention efforts.

Reporting Party Contact Information

If you wish to submit a report anonymously, you should not include any identifying information with your submission, such as adding your name, phone number, and/or email address or using your name in the description of the incident(s). If you provide identifying information when submitting this report, a designated person from the Office of Student Affairs will follow up with you to discuss your report.

First Name:

Last Name:

Phone (XXX-XXX-XXXX):

Email:

Please identify the type of concern you are reporting:

Student Mistreatment ConcernLearning Environment ConcernConcern about a Student/Resident/Faculty/Staff/UnitInadequate Clinical SupervisionI am not sure

At which campus did the incident(s) occur?

Charleston CampusAnderson Campus

Individual(s) Involved in the Incident

Please provide first and last name of the individual you are reporting.

What is the individual's Department/Program/Unit, etc.?

If Other, please describe:

Please provide full names and role for any other faculty/staff or students who were present during the incident.

Information About The Incident(s)

Date(s) of Incident - please provide best estimate or date range:

Location(s) of Incident:

Please provide as much detail as possible regarding the incident/concern using specific, concise, and objective language (Who, what, where, when, why, and how).

What happened? Please describe, in great detail, the concern, incident, and/or behavior(s) that you observed.

What were the impacts of the behavior or incident? How were others affected?

Please describe any attempts made to address the situation, including the identity of any individuals to whom the situation was reported and how the report was received.

Is there anything else you would like to add?

Do you request that a designated individual in the Office of Student Affairs follow up with you to discuss this report?

Yes (please make sure you have included your contact details above)No (We will not be able to contact or follow-up with you individually about this report)

If you would prefer not to complete this form or you have any questions related to the form or the process, we encourage you to contact the MUSC College of Medicine Associate Dean for Student Affairs & Professionalism at (843) 792-2081 or higginel@musc.edu, regarding options for next steps.

Title IX Disclaimer:

If there are any reported concerns involving sex or gender harassment or discrimination, then the concern will be forwarded to and adjudicated by the MUSC Title IX office as per University policy.