RSPN Complaints/Grievance Form

Project Name

Location

Email

Phone Number

Gender
SelectMaleFemaleDiverse

Do you fear the risk of retaliation for sharing your concerns with RSPN?
YesNo

Do you want us to keep your identity confidential?
YesNo

Are you a representative making this complaint on behalf of the complainant(s)?
YesNo

THE COMPLAINTS

Does your complaint relate to either one or several of the following aspects

1. Social harm:

Describe the harm:

Were the social impacts directly by the mentioned project?

Please also describe how you, or those you represent, are or may be adversely affected by the project:

2. Environment harm:
Note: The ICM can entertain complaints of environmental harm that are general as well as personal.

If you are complaining about environmental harm, please describe the harm:

Are you directly affected by the environmental harm described above?

If yes, could you describe how you are affected?

Misuse of funds and/or corruption and/or economic crime

Please describe what has happened, when it did occur and by whom:

Has this occurred before?

Reprisals/retaliation related to the project or a complaint:

Please describe what has happened to you and by whom:

Has this occurred before?

I confirm that the information submitted is truthful to the best of my knowledge:
YesNo

ADDITIONAL INFORMATION (OPTIONAL)

Have there been other efforts made, or are being planned, to resolve the complaint? This may include access to grievance/redress mechanisms of implementing organisation or other dispute resolution processes

YES (EXPLAIN)

NO (EXPLAIN)

Name of the employee(s) in the implementing organisation with whom the complainant(s) had contact (where applicable):

Additional documents/files:

I request that the RSPN ICM to registers this complaint and initiates its redress process:
YesNo