WORKPLACE SEXUAL HARASSMENT COMPLAINT FORM

Kindly read the terms and conditions mentioned below before filling this form. The completely filled form should be sent by e-mail to icc.nou@gmail.com .

Note: The complaint need to be filed before the end of 3 months from the time of harassment.

( Fill NA for not available/not applicable)

1. Personal Details
Your Name
Address
Residence
Office
Mobile No
Email
2. Perpetrator Details
Name of the person (who has or is inflicted the incident/harassment on you)
Designation
Address (Kindly fill NA for not available/not applicable)
Residence
Office
Mobile No
Email
3. Organization Details
Name of Head of the organization
Designation
Address (Kindly fill NA for not available/not applicable)
Office
Mobile No
Email
4. Immediate Leadership
Name of Head of the Department/ Reporting Head
Address (Kindly fill NA for not available/not applicable)
Office
Mobile No
Email
5. Questionnaire
(i)Please indicate the type/types of actions that you feel might have been inflicted by the perpetrator
(ii)Please indicate if you have discussed the matter with someone
Name of the person
Relationship
Mobile No
Email
(iii)Please describe the incidents that have been inflicted upon you
within 500 words, in any language of your convenience
Cancel
Terms and Conditions:

Kindly note, that the information provided by you, will remain completely confidential. Your prior consent will be sought before sharing the information provided by you with any other person /organization apart from the Internal Complaints Committee of North Orissa University, including your own department/section. Your name will remain a complete secret and anonymous in all our communications with your employer/ government authorities or any other body outside NOU. The providing of information in this form provides an authorization from your end to the University authorities to represent and take up any incidents of workplace sexual harassment that might have been inflicted upon you and you at any time could withdraw the right to representation by writing in person on the same. However, if no communication is received from your end then the representation will remain valid. The redressal mechanism may or may not include legal/ psychological mentoring and guidance.