Complaint Form

Primary Community Involved:

Name of the person(s) or organisation(s) filing the complaint:

Which gender do you identify with?:
The information collected is to improve the IRM’s responsiveness. The responses received will be kept strictly confidential.

E-mail Address:

Telephone Number:

Country:

Address:

Is there a representative making this complaint on behalf of the complainant(s)?:

Yes No

Complainants have a right to confidentiality at any time. For example, if you fear retaliation, the IRM can handle complaints keeping the complainant identity confidential. Do you want us to treat your identity confidential?:

Yes No

Title or description of the Chaco Vivo project or programme:

If known, please provide the project number (optional):

Location of the project or programme. Please be as specific as possible.:

If known, please provide the name of the implementing agency (optional):

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

Do you believe Chaco Vivo has failed to comply with its own policies and procedures? (optional):

Yes No

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

Yes No

I request that the IRM registers this complaint and initiates its redress process.:

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