Workplace Sexual Harassment Complaint Form
Kindly read the terms and conditions mentioned below before filling this form.  
       
( Fill NA for not available, not applicable)      
Personal Details      
 
Name
Address Residence
Office
Mobile
Telephone
Email
   
Perpetrator Details  
   
Name of the person who has or is inflicted the incident on you
Designation
Mobile No
Address ( Kindly fill NA for not available, not applicable)
Residence
Office
Mobile
Telephone
Email ( Official )
   
Organization Details (If working in an MNC kindly provide information about both Indian and parent organization)
   
Top Leadership  
   
Name of CEO/ Head of the organization( if based in India )
Address
Residence
Office
Mobile
Telephone
Email ( Official )
   
Global ( only applicable if your head of department is based outside India)
   
Name of CEO/ Head of the organization( if based in India )
Address
Residence
Office
Mobile
Telephone
Email ( Official )
   
Immediate Leadership
   
Name of Head of the Department/ Reporting Head (if based in India )
Address
Residence
Office
Mobile
Telephone
   
Global ( only applicable if your head of department is based outside India)
   
Name of CEO/ Head of the organization( if based in India )
Address
Residence
Office
Mobile
Telephone
Email ( Official )
 
Subsidiary Leadership Head of Human Resources
   
Name
Address
Residence
Office
Mobile
Telephone
Email ( Official )
   
Questionnaire  
   
Please indicate the type/types of actions that you feel might have been inflicted by the perpetrator( Pls select applicable)
Abusive or Sexually Explicit Comments    
       
Showing or displaying of Objectionable material  
       
Sexual advances    
       
Others    
       
Please indicate if you have discussed the matter with someone
   
Name of the person
Relationship
Contact Number ( Mobile )
Email
   
Please write description of the incidents that have been inflicted upon you ( in 700 words only)

characters left
Terms and Conditions
   
Kindly note that the information provided by you will remain completely confidential. Your prior consent will be seeked before sharing the information provided by you with any other person /organization apart from Centre for Transforming India( CFTI) including your own organization. Your name will remain a complete secret and anonymous in all our communications with your employer/ government authorities or any other body outside fold of CFTI
   
The providing of information in this form provides an authorization from your end to CFTI to represent and take up any incidents of workplace sexual harassment that might have been inflicted upon you and you at any time could withdraw the right to representation by writing in person on the same. However if no communication is received from your end then the representation will remain valid.
   
Also note that CFTI will take the issue with your employers/government bodies on effective redressal of the same and might chose multiple methods for the same.
   
The rederssal mechanism may or may not include providing legal/ psychological mentoring and guidance . In cases where legal recourse is required CFTI might guide to a proper legal advisor however the relationship between you and any third party( including the legal advisor) is solely among you and the party and CFTI will not be a party to any relationship in the same.
   
Self Certifications  
I certify that the information mentioned above is true to the best of my knowledge and I am fully aware that any misrepresentation of the same would result is my disqualification from the process of rederssal. Further I indemnify CFTI against any legal action that might be undertaken by my employer or myself
   
I am fully aware that the decisions of Centre for Transforming India on the cases to be considered for rederssal and the process will not be challenged by me in the court of law and will remain final and binding on me.