Annex 3: Sample Grievance Form GRIEVANCE FORM Grievance Number Copes to forward to: Name of Recorder (Original) –Receiver County/District/Settlement (Copy) – Responsible Party Date INFORMATION ABOUT GRIEVANCE Define the Grievance Name Surname of – Receipt Telephone no Phone line Address Village/Settlement Community Information District/Province Informal Signature of Complainant Other DETAILS OF GRIEVANCE 1. Access to Land 2. Damage to 3. Damage to 4. Decrease or 5. Traffic and Resources infrastructure or Loss of Accident community Assets Livelihood a) Lands a) Land a) a) Agriculture a) Injury b) Fishing Grounds b) house b) Power/Telephone b)Animal b) Damage to c) Pasture Land c) livestock lines Husbandry property d) d) Means of c) sources, c) Beekeeping c) Damage to e) Commercial site Livelihoods canals and water d) scale livestock f) Others e) Other infrastructure for trade d) irrigation and e) animals d) Drinking water e) Sewage System f) Other 6.Incidents 7. Resettlement 8.Employment and 9. Construction 10. Other Regarding Process Recruitment Camp and (Specify) Expropriation (Specify) (Specify) Community And compensation Relations (specify) a)Nuisance from dust b) Nuisance from noise c) Vibration due to explosion d) Misconduct of the project personal/worker e) Complaint follow-up f) Other
Annex 3: Sample Grievance Form GRIEVANCE FORM Grievance Number Copes to forward to: Name of Recorder (Original) –Receiver County/District/Settlement (Copy) – Responsible Party Date INFORMATION ABOUT GRIEVANCE Define the Grievance Name – Surname of Receipt Telephone no Phone line Address Village/Settlement Community Information District/Province Informal Signature of Complainant Other DETAILS OF GRIEVANCE 1. Access to Land and Resources 2. Damage to 3. Damage to infrastructure or community Assets 4. Decrease or Loss of Livelihood 5. Traffic Accident a) Lands b) Fishing Grounds c) Pasture Land d) e) Commercial site f) Others a) Land b) house c) livestock d) Means of Livelihoods e) Other a) b) Power/Telephone lines c) sources, canals and water infrastructure for irrigation and animals d) Drinking water e) Sewage System f) Other a) Agriculture b)Animal Husbandry c) Beekeeping d) scale trade e) a) Injury b) Damage to property c) Damage to livestock d) 6.Incidents Regarding Expropriation And compensation (specify) 7. Resettlement Process (Specify) 8.Employment and Recruitment (Specify) 9. Construction Camp and Community Relations 10. Other (Specify) a)Nuisance from dust b) Nuisance from noise c) Vibration due to explosion d) Misconduct of the project personal/worker e) Complaint follow-up f) Other