A harassment complaint form lets an employee report harassment at work and directs the complaint to the right forum. Complaints of sexual harassment are addressed to the Internal Committee under the POSH Act 2013, while other harassment, such as harassment based on caste, religion, disability or region, is addressed to HR under the company's anti-harassment policy.
Evidence available (messages, emails, photographs)
Has this been reported to anyone before? Details
Impact on you
Section E: Interim Relief Requested (if any)
Transfer of complainant or respondent
Change of reporting line or shift
Leave
Restraint on respondent from contacting me
Other
Section F: Declaration
I submit this complaint voluntarily and declare that the information is true to the best of my knowledge. I understand that the complaint will be handled confidentially by the Internal Committee or HR as applicable, that I will be informed of the process, and that I am protected from victimisation or retaliation for making this complaint.
Clear routing box: Internal Committee for sexual harassment, HR for other harassment
Complainant details with a safe contact
Respondent details, including third parties
Incident details with dates, place and description
Witnesses and evidence
Interim relief requested, such as transfer or leave
Confidentiality and non-retaliation declaration
When to use it
A woman employee wants to file a written sexual harassment complaint with the Internal Committee
An employee faces harassing remarks about caste, religion, region, disability or appearance
Harassment occurs from a client, vendor or visitor in a work context
HR needs a form that safely routes complaints to the correct process
How to customise this template
1Insert the names and contacts of your Internal Committee presiding officer and members
2Mention your POSH policy and anti-harassment policy titles
3Provide a sealed-envelope or dedicated email option for submission
4Translate the form into regional languages
5Display IC details on notice boards along with this form
HR tips
HR should not investigate sexual-harassment complaints itself; hand them to the IC promptly
Do not ask the complainant to confront the respondent
Never disclose the complainant's identity beyond those who need to know
Help a complainant who cannot write to put the complaint in writing
This template is a starting point. The POSH Act 2013 and its rules set specific procedures and timelines for sexual harassment complaints; review the form with your Internal Committee and a legal adviser.
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Frequently asked questions
Where should a sexual harassment complaint be filed?+
With the Internal Committee of the employer under the POSH Act 2013. Employers with 10 or more employees must constitute an IC.
Can men file a harassment complaint?+
The POSH Act covers complaints by women. Many companies have a gender-neutral anti-harassment policy so that any employee can complain to HR or a designated committee.
Is the harassment complaint kept confidential?+
Yes. The identity of the complainant, respondent and witnesses and the proceedings must be kept confidential.
Can I ask for interim relief?+
Yes. The complainant can request interim measures, such as a transfer of either party or leave, during the inquiry.
This form is used to report conduct that you believe breaches company rules or the code of conduct. All complaints are treated confidentially. If your complaint relates to sexual harassment, please approach the Internal Committee directly as per the company's POSH policy.
1. Complainant Details
Employee Name
Employee ID
Designation
Department
Work Location
Contact Number
Preferred mode of contact
2. Person(s) Complained Against
Name
Designation / Role
Department or Organisation (if vendor/customer)
Relationship to you (colleague, supervisor, vendor, other)
Anyone working at this site may use this form. You may give your name or leave it blank. For complaints of sexual harassment please contact the Internal Committee: [IC Presiding Officer Name], [Phone].
Use this form to report a suspected breach of the Code of Conduct. You may remain anonymous. Submit to [Ethics Email] or the sealed ethics box at [Location]. Sexual harassment complaints should be made to the Internal Committee.
This disclosure is made under the company's Whistleblower / Vigil Mechanism Policy. Mark the envelope 'Protected Disclosure – Confidential' or email [Vigilance Email]. Your identity will be protected.
1. Whistleblower Details (kept separately and confidential)
Name
Employee ID
Designation / Department
Safe contact
I wish to remain anonymous (Yes / No)
2. Nature of Wrongdoing
Financial fraud or misappropriation
Manipulation of accounts or records
Violation of law or regulation
Falsification of safety, quality or test data
Abuse of authority
Leak of confidential or price-sensitive information
Use this form to formally raise a work-related grievance. Please write clearly and attach any supporting documents. Complaints of sexual harassment must be submitted to the Internal Committee under the company's POSH policy and not on this form.