COMPLAINT FORM


Every instance of violation of a child's Right to Protection must be registered in writing and brought to the attention of the relevant Child Protection/ Gender Inclusion Executive Committee in the area. To file a formal complaint, please fill out this form completely in writing and submit it to any person on the Committee. If you need help completing the form, or want to discuss the issue before completing the complaint form, you can approach any person in the Committee or any person you trust within or outside the organisation.

 

PART I: Person(s) Submitting the Complaint

Name of the Person completing this form __________________________________________________

 

Tick any one of the following:

􀀀 I am the child making the complaint

􀀀 I am the child's parent/guardian

􀀀 I am a The Footpath Scholar staff member

􀀀 Other

 

1. Name of the Complainant: __________________________________________________

 

2. Address of the Complainant: ________________________________________________________________________________________________________________________________________________

 

3. Telephone number of the Complainant: ________________________________________

 

4. If you would like to have your parent(s), guardian(s), or another person attend a meeting with the Committee please provide the following information:

Name of the person/s: ________________________________________________________

Address: ________________________________________________________________________________________________________________________________________________

Telephone # __________________________ Relationship__________________________

 

PART II: Complaint

 

5. Please describe the situation that has caused you to complain ________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Date/ Time Period of the Incident: ____________________________________________

Location of the Incident: ______________________________________

Description of the Incident: ________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Person/s who witnessed the Incident: ________________________________________________________________________________________________________________________________________________

 

Please share with us how this incident has affected you so that we can know best how we can be of help to you. ________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

6. Please describe any efforts you have made to resolve your complaint informally and the responses to your efforts. ________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Date: __ __  / __ __ / __ __ __ __  (DD/MM/YYYY)

 

With whom did you share your experience? ________________________________________________________________________________________________________________________________________________

 

Describe the conversation and the response you received. ________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

7. (OPTIONAL) Please describe the outcome or remedy you seek for this complaint.

________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

 

Signature of Person Submitting Report____________________________

 

Signature of member, Executive Committee for Child Protection/ Gender Inclusion: _________________________________

Date Filed________________________________________