University of Miami, Workplace Equity and Performance
Complaint Form

Complete this form to complain of prohibited discrimination and/or harassment and return the form to Workplace Equity and Performance. Completion of this form is not required to formally initiate a complaint, however completing the form will assist the review/investigation process. You will be contacted as soon as possible for a confidential interview.

Please review our privacy statement relating to information we collect, choice/opt-out, and correction/updating of personal information before proceeding.

* Name (You must type in a response)
 
 
Home Phone (Type in a response)
 
 
Work Phone (Type in a response)
 
 
Cell Phone (Type in a response)
 
 
Job Title (Type in a response)
 
 
Department (Type in a response)
 
 
* Supervisor (You must type in a response)
 
 
* Supervisor Phone (You must type in a response)
 
 
Identify the Respondent(s) and/or Department you allege discrimination against you. (Type in a response)
 
 
Name of Respondent (Type in a response)
 
 
Department (Type in a response)
 
 
Phone Number (Type in a response)
 
 
Indicate the basis for the alleged prohibited discrimination and/or harassment: (Select at least one)
 
Age
Disability
Family Medical Leave Act
Gender (Sex)
Marital Status
National Origin
Pregnancy
Race/Color
Religion
Retaliation
Sexual Harassment
Sexual Orientation
Veteran's Status
Other
 
Briefly explain the discrimination and/or harassment you believe happened: (Type in a response)
 
 
On what date(s) did the alleged discriminatory act(s) occur? (Type in a response)
 
 
Explain the incident that occurred: (Type in a response)
 
 
I certify that the information supplied is true and correct to the best of my knowledge.
 
   

Your form has been submitted. Someone from Workplace Equity and Performance will be contacting you. If you have any questions please contact our office at the Coral Gables campus (305) 284-3064 or the Miller School of Medicine (305) 243-7203.