Complaint form of Sexual Harassment

IIHMR UNIVERSITY JAIPUR- 302029

INTERNAL COMPLAINTS COMMITTEE

Email- icc.chairperson@iihmr.edu.in

Format for Filing Complaints of Sexual Harassment

The processing of this complaint by the ICC is subject to physical validation through signature in the ICC Chairperson Office by the complainant(s) within THREE WORKING DAYS of online submission.

In order to ensure accessibility and confidentiality for the complainant(s), the ICC will arrange for the signature inside the University campus.

I. Complainant(s):
Student/resident/academic staff/ non-teaching staff/outsider/service provider

Complainant(s):*

Name of the Complainant *

Name of Father of the Complainant*

Name of Mother of the Complainant*

Age (in completed Years)*

Sex / Gender identity*

Official Address*

Residential Address*

Permanent Address

Centre/School/Department/Company Name*

Email ID

example@example.com

Phone no*

II. Person(s) against whom the complaint is being lodged:
Student/resident/academic staff/ non-teaching staff/outsider/service provider

Person(s) against *

Name*

Designation*

Age (in completedYears)*

Sex / Gender identity*

Address*

Centre/School/Department/Company Name*

Email ID

example@example.com

Phone No*

III. The Complaint:

Is the defendant known to the complainant?*

YesNo

Is this the first incident of this kind?*

YesNo

Date*

Date

Time*

:HourMinutesAM/PM Option

Location*

Any other relevant information

Additional details of the complaint may be sent directly to the ICC Chairperson: icc.chairperson@iihmr.edu.in

Complaint filed by

Name Signature Date Palce .