Internal Compliant Committee & Sexual Harassment Committee

FORM FOR FILING COMPLAINT OF SEXUAL HARASSMENT AT WORKPLACE

(To be filled by aggrieved women or others on her behalf)
(This complaint form along with supporting documents must be submitted to ICC, LCC or shebox.wcd.nic.in)
(The complainant must fill in all the required information and provide signature on each page of this form)

THIS FORM CONSISTS OF FIVE PARTS

Part -1 Details of Complainer
Part -2 Details of aggrieved women
Part -3 Details of Respondent
Part -4 Description of sexual harassment
Part -5 Details of witnesses and evidences

Part - 1 Details of Complainer

Date of Complaint Filing:

Full name of complainer:

Gender:

Contact Details of complainer (Mobile No.):

Email:

Date of Birth of Complainer:

Residential Address of complainer (Present):

Residential Address of complainer (Permanent):

Have you undergone any treatment by a psychiatrist or physician due to the sexual harassment committed by the respondent? (attach the supporting documents)

Name of Employer with address where complainer is working:

Designation of Complainer:

Duration of Employment:

Work ID of the complainer:

Relation of complainer with aggrieved women (mention self if filing herself):

(Co-worker, employer, reporting manager etc.)

Description:

Describe the physical and mental suffering aggrieved women experiencing now due to the sexual harassment committed by the respondent.

Part - 2 Details of aggrieved women

Full name of aggrieved women (victim women):

Contact Details of aggrieved women (Mobile No.)

Email :

Date of birth of aggrieved women:

Residential Address of aggrieved women (Present):

Residential Address of aggrieved women (Permanent):

Name of Employer with address where aggrieved women is working:

Designation of aggrieved women:

Duration of employment with present employer:

Signature of Complainer:

Work ID of the aggrieved women:

Part - 3 Details of Respondent

Full name of respondent (against whom complaint is filled):

Contact Details of respondent (Mobile No.):

Email :

Residential Address of respondent (Present):

Residential Address of respondent (Permanent):

Name of Employer with address where respondent is working:

Designation of respondent:

Working relation of aggrieved women with respondent (Employer, Reporting Manager, co- employee, junior staff, other) :

Part - 4 Description of sexual harassment

Number of sexual harassment incidences done by the respondent:

Are aggrieved women and responded working in the same organization or same department when the incidence of sexual harassment happened?

What was the date of last incidence of sexual harassment?

Mention date and time wise description of sexual harassment done by respondent: - (take additional sheet if required)

Date-1:

Time:

Place:

Description:

Date-2:

Time:

Place:

Description:

Signature of Complainer:

Describe the physical and mental suffering aggrieved women experiencing now due to the sexual harassment committed by the respondent.

Have you undergone any treatment by a psychiatrist or physician due to the sexual harassment committed by the respondent? (attach the supporting documents)

Part - 5 Details of witnesses and evidences

Is there any evidence or eyewitness of sexual harassment committed by the respondent? (ICC can call and cross check witnesses and evidences during redressal)

Mention details of evidence of the incidence for supporting your complaint:

Full name of witness:

Contact Details witness (Mobile No.)

Email :

Residential Address of witness (Present):

Residential Address of witness (Permanent):

Name of Employer with address where witness is working:

Designation of witness:

Working relation of aggrieved women with witness (Employer, Reporting Manager, co-employee, junior staff, other):

Declaration:

I (Full name of complainer)

filing complaint of sexual harassment on this date and day

against (Name of responder)

I declare that the above information given by me in this complaint is true and best of my knowledge. I am responsible for this complaint filed by me and aware that I can be punished for any malicious or false complaints.

Signature of Complainer

Signature of the complainer

Date:

Place:

Attachments: 1) Concern letter of aggrieved women in case of complaint filed by any other person. 2) Evidences if any

Maximum file size: 33.55MB

Signature of Complainer

If you are human, leave this field blank.

Shri Yashwant Shikshan Prasarak Mandal Kodoli’s

Yashwant Ayurvedic College Post Graduate Training & Research Centre, Kodoli

Tal. Panhala, Dist. Kolhapur – 416114