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Required format:

/^((0?[1-9])|([1-8][0-9])|(9[0-8]))[0-9]{3}$/

/^((29([-\/])02\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1\d|2[0-8])([-\/])(0[1-9]|1[012]))|((29|30)([-\/])(0[13-9]|1[012]))|(31([-\/])(0[13578]|1[02])))(\11|\15|\18)\d{4}))$/

/^((02([-\/])29\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1[012])([-\/])(0[1-9]|1\d|2[0-8]))|((0[13-9]|1[012])([-\/])(29|30))|((0[13578]|1[02])([-\/])31))(\11|\15|\19)\d{4}))$/

/^(((\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00))([-\/])02(\6)29)|(\d{4}([-\/])((0[1-9]|1[012])(\9)(0[1-9]|1\d|2[0-8])|((0[13-9]|1[012])(\9)(29|30))|((0[13578]|1[02])(\9)31))))$/

/^(((\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00))([-\/])02(\6)29)|(\d{4}([-\/])((0[1-9]|1[012])(\9)(0[1-9]|1\d|2[0-8])|((0[13-9]|1[012])(\9)(29|30))|((0[13578]|1[02])(\9)31)))) (\d|[0-1]\d|[2][0-3]):[0-5]\d$/

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/^[-+]?\b\d+\b$/

/^[a-z]+$/i

/^\d{10}$/

/^[a-z0-9-_]+$/i

/^[-+]?[0-9]*\.?[0-9]+([eE][-+]?[0-9]+)?$/

/^-?\d+,\d$/

/^-?\d+\.\d$/

/^-?\d+,\d{2}$/

/^-?\d+\.\d{2}$/

/^-?\d+,\d{3}$/

/^-?\d+\.\d{3}$/

/^-?\d+,\d{4}$/

/^-?\d+\.\d{4}$/

/^[-+]?[0-9]*,?[0-9]+([eE][-+]?[0-9]+)?$/

/^($0[2-8]$|0[2-8])\s*\d{4}\s*\d{4}$/

/^(?:$?([2-9]0[1-9]|[2-9]1[02-9]|[2-9][2-9][0-9]|800|811)$?)\s*(?:[.-]\s*)?([0-9]{3})\s*(?:[.-]\s*)?([0-9]{4})(?:\s*(?:#|x\.?|ext\.?|extension)\s*(\d+))?$/

/^((((\+44|0044)\s?\d{4}|$?0\d{4}$?)\s?\d{3}\s?\d{3})|(((\+44|0044)\s?\d{3}|$?0\d{3}$?)\s?\d{3}\s?\d{4})|(((\+44|0044)\s?\d{2}|$?0\d{2}$?)\s?\d{4}\s?\d{4}))(\s?\#(\d{4}|\d{3}))?$/

/^\d{4}$/

/^[ABCEGHJKLMNPRSTVXY]{1}\d{1}[A-Z]{1}\s*\d{1}[A-Z]{1}\d{1}$/i

/^(0[1-9]|[1-9]\d)\d{3}$/

/^\d{3}-\d\d-\d{4}$/

/./

/^(\d|[01]\d|(2[0-3]))(:[0-5]\d){2}$/

/^([0-9]|[0-1][0-9]|[2][0-3]):([0-5][0-9])$/

/^[0-5]\d:[0-5]\d$/

/^[0-9]{4,9}$/

/^\d{5}(-\d{4})?$/

hRAq6ezu4DMJHpNoNNZBdbWBJjLHhNI5kJDwcuezfsp6FbsHkEpv3To8

KUMC Complaint of Discrimination Form

This link was created to provide an avenue to report discrimination as quickly as possible. If you have any questions about anti-discrimination laws, KUMC policies, or KUMC procedures, visit the EOAC website and click on the discrimination tab on the left.

The University of Kansas Medical Center prohibits all forms of discrimination and strongly supports efforts to enable all individuals to realize their full potential. To this end, KU Medical Center is committed to providing an equal opportunity for all qualified individuals to participate in conditions of employment and in academic programs and activities, regardless of an individual's race, religion, color, ethnicity, sex, disability, national origin, ancestry, age, status as a veteran, sexual orientation, marital status, parental status, gender identity, gender expression, or genetic information Click on the following link to review KU Medical Center's Discrimination Complaint Resolution Process.

To discuss any questions or concerns regarding possible discrimination, please contact the Equal Oportunity Office at (913) 588-8011 or nholick@kumc.edu.

All University of Kansas components share in the commitment to provide a working and learning environment free from discrimination and harassment. The following University policies reflect that commitment and apply to all campuses, including the KU Medical Center:

Non-Discrimination Equal Opportunity Affirmative Action Policy

Sexual Harassment

IF YOU ARE A PATIENT, DO NOT COMPLETE THIS FORM. Contact patient relations at patientrelations@kumc.edu or by phone at 913.588.1290.

First Name:

* must provide value

Last Name:

* must provide value

Best way to reach you:

Street Address:

City:

State:

Phone:

* must provide value

Phone Type:

Email:

* must provide value

Affiliation:

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PLEASE NOTE: This form routes to the University of Kansas Medical Center. If you are an employee of the University of Kansas Health System or wish to report a concern regarding a UKHS employee, please do not complete this form but instead report the matter through the UKHS hotline: 844-527-0597.

If you are a patient of the KU Health System or wish to report a concern regarding a patient, please do not complete this form but instead contact the KU Health System's Patient Relations Office at 913-588-1290 or by email at patientrelations@kumc.edu.

Department/School/Program:

* must provide value

Your Supervisor (if applicable)

Please Identify the protected category(ies) on which you base your claim of discrimination:

* must provide value

Age

Gender Identity/Gender Expression

Marital Status/Parental Status

Race or Color

Religion or Religious Accommodation

Sex/Sexual Harassment/Pregnancy

Sexual Orientation

Disability

Genetic Information

National Origin/Ethnicity/Ancestry

Retaliation because you filed a complaint or asserted your right

Sexual Assault/Sexual Violence

Status as a Veteran

If your complaint is based on sexual harassment, sexual assault, domestic violence, partnership violence or stalking, please fill out the Title IX Intake Form instead of this discrimination complaint form.

For more information, please review the Title IX Resolution Process.

What date did the discrimination take place or begin? (mm/dd/yyyy)

First Name:

* must provide value

Last Name:

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Department/School/Program:

* must provide value

Filed with other agencies?

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Yes

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Please identify the other agencies:

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Have you pursued resolution of your complaint through the internal grievance or any informal process with your department or outside of your department?

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Yes

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Please describe resolution efforts:

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Please describe the alleged discrimination of harassment, including the dates the discrimination action(s) occurred; name(s) of individual(s) who discriminated; witnesses (if any); and why you believe the discrimination was based on the protected category you indicated above, or why you believe the action was retaliatory, and provide the factual basis for your belief that discrimination has occurred.

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To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.