Program of Study: USC Physical Therapy Program

Physical Therapy Program
Department of Exercise Science
Arnold School of Public Health
Blatt Building
University of South Carolina
Columbia, SC 29208

e-mail: dptinfo@gwm.sc.edu
Phone: 803-777-5521
Fax: 803-777-8422

Physical Therapy Program

INDIVIDUAL REFERRAL FORM
Individuals (i.e., Faculty, Staff, Students, or members of the community) may use this form to bring to the attention of the Program Director any behaviors by a faculty or staff member or student that are inappropriate or unprofessional. (If you have a concern regarding the Program Director, please contact the Chairperson of the Department of Exercise Science 803-777-7680). This referral may be made anonymously or when possible the individual completing the form should identify themselves so that action taken may be reported.
	* required fields
* Name of individual you are reporting:
* Behavior that is of concern:	Note: Use the Control key to select or deselect multiple items.
* Describe the incident/s observed:
Your name (optional):
Email Address:
Phone Number:

Columbia, SC 29208 • 803-777-5521 • dptinfo@mailbox.sc.edu