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Sexual Harassment Complaint Form

Important Instructions:

1. We assure you that any information given by you will be kept strictly confidential.
2. You may leave the columns/fields blank for which you don't have any information or you do not want to fill. But the fields with (*) in front of them are compulsory.
3. Once you fill and submit the form, preview of the form will be shown to you with the information you have filled, if you wish you may take the printout of the preview page for your record.
4. In case of fake complaints displinary action will be taken by the authorities.
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Date of Complaint  20-June-2019
1. Personal Details
You Are (*) Student   Employee   Research Scholar  
Your Name (*)
Select Your Campus(*)
Your Branch / Department (*)
-
-
Contact No. (*)
Email ID 
2. Perpetrator Details (Details of the person who has or is inflicting harassment on you) :
Name (*)
Branch / Department (*)
He is (*) Student   Employee   Research Scholar  
-
Contact No .
Email ID 
3. Please indicate the type/types of actions that you feel has/ have been inflicted by   the perpetrator (*) Abusive or sexually explicit comments
Showing or displying of objectionable material
Physical advances
Demand for sexual favours
Others
4. Please indicate if you have discussed the matter with someone in the university or at your campus
Name 
Designation 
Branch / Department 
Contact No. 
Did he/she/they take any necessary action   Yes     No
5. Witness Details 
If You have any witness, to add witness details.
6. Describe Grievance
Please write description of the incident that has been inflicted upon you (*)  
NOTE : Kindly mention date, time and place of incident along with other details.
7. Do you have any proofs?
Are there any documents or emails etc. which contain information supporting the
occurance described above
  
No proofs available
Recording
SMS
MMS
Written material
Physical Evidence
Others
Enter the Security Key shown in figure (Case Sensitive) VwNq
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