Anonymous Reporting Form
For Sexual Harassment
Are you reporting on behalf of:
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Yourself
Someone else who is a staff member of South Coast Medical Group
Are you:
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A member of staff of South Coast Medical Group
A visitor to any of the sites owned by South Coast Medical Group (i.e. a student, trainee, volunteer, contractor, etc.)
How do you identify your gender?
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Male
Female
Prefer not to say
Please tell us why you are reporting anonymously
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I am worried that I will not be believed
Making a complaint would have a negative impact on my health
I do not want anyone to know it took place
I cannot prove the behaviour took place
I have concerns it might affect my current/future career
I feel partly to blame for what happened
I do not know how to make a complaint
I reported it to someone at South Coast Medical Group but they did not take it seriously
I am worried that there would be repercussions in my social circle
I do not want to get the other person into trouble
I feel too embarrassed or ashamed
I am worried about being called a trouble maker
I am worried the perpetrator would retaliate
I do not have time to make a complaint
The victim did not want to report it themselves
Nothing would be done if I made a complaint
It is not serious enough to warrant a complaint
Have you sought support?
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Yes, I have sought support from a friend or family member
Yes, I have sought support from a colleague from South Coast Medical Group
Yes, I have sought support from an external support organisation
No, but I will seek support soon
No, I do not want to seek support right now
When did the incident take place?
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In the last week
In the last month
In the last year
Over a year ago
Where did the incident take place?
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On South Coast Medical Group property
Within the Bournemouth area
Outside of the Bournemouth area
The perpetrator(s) was/were:
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A South Coast Medical Group member of staff
A registered patient
A relative of a registered patient
A visitor to the Practice, e.g. a contractor
A student or trainee
Someone known to me/the victim
A stranger to me/the victim
I am not sure
Confirm the type of behaviour that took place:
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Making offensive comments aboutsomeone’s personal traits or assumed personal traits
Treating someone differentlybecause of their personal traits or assumed personal traits
Controlling or coercive behaviour
Inappropriate use of social media
Physical misconduct (hitting, pushing, spitting, hair pulling, etc.)
Repeatedly following another person
Inappropriately showing sexual organs to someone
Inappropriate touching without consent
Kissing without consent
Sharing private sexual materials of another person without consent
Engaging in sexual intercourse or a sexual act without consent
Antisemitic behaviour
Islamophobic behaviour
Discrimination linked to other religious identities
Discrimination linked to having no religious identity
Other
Was the behaviour linked to real or perceived personal traits?
Age
Disability
Gender
Sexual orientation
Ethnicity
Religion or belief
Transgender status
Caring responsibilities
Nationality
I don't know
Do you think there was action required by South Coast Medical Group to avoid or prevent the incident?
Yes
No
Please enter further details
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Do you think there is any further action required by South Coast Medical Group now or in the future to address the incident?
Yes
No
Please enter further details
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Submit
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