Reporting Misconduct

CPCE General Assembly Complaint Form

This form should be completed by the person wishing to lodge a complaint or documented by a third party. All information must be held securely and confidentiality must be maintained at all times.

A: General data

Name of the person lodging the complaint: ______________________________

Gender: ______

Age: ___

Hotel/Address:_____________________________________________________________________

Tel: _______________________________________ email: __________________________________

Name of the person you wish to lodge a complaint against (if known): _______________________

Date of incident: ____________________________________

Time of incident: ___________________

Place of incident: ______________________________________________________________

Date of reporting: __________________________________

Time of reporting: ___________________

Preferred communication channel: phone ; email ; in person: ___________________________

B: What is the complaint?

(State the nature and key issue of the Complaint)

C: Brief description of the incident or concern:

State what exactly happened, trying to follow the sequence of events from start to finish. If the incident location is not well known, describe the location based on your memory of it. Give a description of the ‘subject of complaint’ if you do not know her/his name.

D: Name of witnesses:

(if any) Supply the names of witnesses and where they can be contacted, if known.

E: Solution options:

State what kind of a response you expect from CPCE and how you wish to see the matter resolved:

Name and Signature of Complainant: _______________________________________________

To be completed by the Committee of Complaints:

Date and time of receipt: ______________________

Dossier number: _________

Persons handling the complaint:

Name and function: ___________________________________________

Date: ________________________________

Case referred to: ___________________________________ Date referred: _____________________

Describe action taken

(provide detailed information example, if medical assistance has been provided, what psychosocial care has been provided and whether a report has been made to the Police):

Name and Signature of representative of Committee of Complaints: ________________