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I.T.S College of Health and Wellness Sciences
(Affiliated with Atal Bihari Vajpayee Medical University, U.P. Lucknow)
46, Knowledge Park – III, Greater Noida - 201 310 (India) | Toll Free: 1800 1800 840, 9258114110 | Email: itschws@its.edu.in
46, Knowledge Park – III, Greater Noida - 201 310 (India) | Toll Free: 1800 1800 840, 9258114110 | Email: itschws@its.edu.in
COMPLAINT FORM
Sexual Harassment of Women Employees and Students in Higher Educational Institutions
Reference framework: UGC (Prevention, Prohibition and Redressal of Sexual Harassment of Women Employees and Students in Higher Educational Institutions) Regulations, 2015.
Confidential: Please submit this form to the institution’s Internal Complaints Committee (ICC) or use it as a written complaint attachment where appropriate.
A. Details of the complainant
| Full name | |
| Status (student / employee / other) | |
| Department / course / designation | |
| Year / semester (if student) | |
| University / college / institution | |
| Affiliating university (if applicable) | |
| Postal address | |
| City, State, PIN | |
| Contact number | |
| Email address |
B. Details of the person against whom the complaint is made
| Name | |
| Designation / role | |
| Department | |
| Relationship to complainant | |
| Research supervisor? (Yes / No / N.A.) |
C. Incident details
| Date(s) and time(s) of incident(s) | |
| Place / location of incident(s) | |
| Nature of complaint / conduct reported | |
| Description of incident(s) (include sequence of events and relevant details) | |
| Names / contact details of witnesses, if any | |
| Was the incident reported earlier? If yes, to whom and when? | |
| Any immediate safety or support concerns |
D. Supporting material
Please list and attach any relevant supporting documents, messages, emails, screenshots, photographs, medical records, or other material, if available. Do not delay submitting a complaint solely because supporting material is unavailable.
| Documents / evidence attached | |
| Other relevant information |
E. Previous or parallel reporting
| Has this matter been reported to the ICC or another authority? (Yes / No) | |
| If yes, provide date, authority, and reference number (if any) | |
| ICC constituted at the institution? (Yes / No / Not known) |
F. Declaration and signature
I confirm that the information provided above is true and accurate to the best of my knowledge and belief. I understand that the institution may contact me for clarification and that the complaint will be handled under applicable rules and procedures.
| Place | |
| Date | |
| Signature / name of complainant |
For office / ICC use only
| Date received | |
| Received by / designation | |
| Diary / reference number | |
| Action / remarks |
