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.
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Date of Complaint  08-August-2022
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
4. Please indicate if you have discussed the matter with someone in the university or at your campus
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
Written material
Physical Evidence
Enter the Security Key shown in figure (Case Sensitive) QrIq