POSH Complaint Form

[COMPANY NAME]
COMPLAINT OF SEXUAL HARASSMENT AT THE WORKPLACE

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Submitted to the Internal Committee constituted under the Sexual Harassment of
Women at Workplace (Prevention, Prohibition and Redressal) Act, 2013.

Before you begin. A complaint should be made within three months of the incident,
or of the last incident in a series. The committee may extend that by a further
three months where circumstances prevented an earlier complaint. If you would like
help writing this complaint, you are entitled to ask for it.

Everything in this form is confidential. The Act prohibits publication or
disclosure of the complainant's identity, the respondent's identity, the contents,
the proceedings and the recommendations, except as it permits.

1. COMPLAINANT
Name:               [Name]
Employee number:    [Employee number]
Designation:        [Designation]
Department:         [Department]
Contact number:     [Phone]
Email:              [Email]

If this complaint is being made on the complainant's behalf, state by whom and
attach her written consent:

2. RESPONDENT
Name:               [Name]
Designation:        [Designation]
Department:         [Department]
Relationship to you (manager, colleague, client, vendor, other):

3. THE INCIDENT OR INCIDENTS
Describe what happened, in your own words. Include the date, time and place of
each incident, and what was said or done. Use additional sheets if you need to.

4. WITNESSES
Anyone who saw or heard what happened, or whom you told about it afterwards.

   Name                          Designation              How they know
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5. DOCUMENTS
List anything you are attaching — messages, emails, photographs, notes made at the
time.

6. WHAT YOU WOULD LIKE TO HAPPEN

7. CONCILIATION
The Act allows the committee, at your request and before an inquiry begins, to try
to settle the matter through conciliation. No monetary settlement may be made the
basis of a conciliation.

   [ ] I would like the committee to attempt conciliation
   [ ] I would like the committee to proceed to an inquiry

8. INTERIM RELIEF
During an inquiry the committee may recommend interim measures — transferring
either party, granting you leave of up to three months in addition to your
entitlement, or restraining the respondent from reporting on your work. Say here if
you would like to request any of these.

DECLARATION
The information given above is true to the best of my knowledge and belief.

Signature: [Signature]          Date: [Date]

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FOR COMMITTEE USE
Received on: ____________    Complaint number: ____________
Received by: ____________    Inquiry to be completed by: ____________ (90 days)
Copy of the complaint provided to the respondent on: ____________