Grievance Form

1. Information of Grievance Raiser (This information must be provided. The identity will be kept confidential if they request so. Anonymous grievances will be accepted, registered and considered, but not answered due to missing feedback route.)

Name: *

Title:

Mr.

Ms.

Mrs.

Position/Organization (If any):

Address:

E-Mail address:

Please indicate how you prefer to be contacted:

E-Mail

Phone

Do you request that identity be kept confidential?

YES

NO

2. Information on Authorized Representative (If any)

Name:

Title:

Mr.

Ms.

Mrs.

Position/Organization (If any):

Address:

Contact number:

E-Mail address:

3. Project Information

Project name:

Project location:

4. The Grievance

(a) What harm/effect do you believe the project caused or is likely to cause to you?

(b) Why do you believe that the alleged harm/effect results directly from the project?

(c) Please include any other information that you consider relevant..

5. Previous Efforts to Resolve the Grievance

(a) Have you raised your grievance before with the grievance mechanism of the project?

Yes

No

If YES, please provide the following: When, how and with whom the issues were raised. | If NO, why not?

If YES, Please describe any response received from and/or any actions taken by the project level grievance mechanism. Please also explain why the response or actions taken are not satisfactory. If NO, please leave blank.

(b) How do you wish to see the grievance resolved?

(c) Do you have any other matters or facts (including supporting documents) that you would like to share?

Grievance Submission Date: