COMPLAINANT DETAILS
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Complainant’s name (Or name of a representative for complainant/s)
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Land parcel number (if applicable)
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Complainant’s postal address
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Complainant’s telephone number and e-mail address (if available)
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Preferred language of communication
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Complainant confidentiality
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☐ I wish to raise my grievance anonymously
☐ I request that my identity is not disclosed to anyone internally except the grievance coordinator handling my case
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I would prefer if the personnel contacting me is: ☐ male, ☐ female, ☐ gender does not matter
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GRIEVANCE DETAILS
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Date :
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Description of incident details (what happened? when? how? where? quantities?)
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Severity
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☐ One time incident/grievance (date _______________)
☐ Recurring (how many times? _____)
☐ On going (currently experiencing problem)
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Complainant’s request/proposal to resolve grievance (Please explain what should be done to solve this problem?)
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Grievance type (environment, human rights, livelihood, health, legal, property, corruption)
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Level of damage:
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☐low
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☐medium
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☐ high
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Additional documentation related to grievance
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Verbal Complaint
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If complainant is verbal and in the case that the compliant cannot read or write, the environmental and social specialist will help to write it down.
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