Annex 8: Grievance Redress Forms Annex 8a. Sample Grievance Redress Form and Agreed Resolution Format Grievance Form Grievance Number: Copies to forward to: Name of the Recorder; (Original)-Receiver Party: LG & Community: (Copy)- Responsible Date: Information About Grievance Define The INFORMATION THE COMPLAINANT Forms of Receipt: Community/Information Meetings Name □ Mail Phone Line □ Informal Village/ Govt. Area □ Other Signature of Complainant and Date □ DETAILS OF GRIEVANCE (addition to list could be made as appropriate) 1. Access to Land 2. Damage to 3. Damage to 4. Decrease or 5. Traffic and Resources a) House Infrastructure or Loss of Accident a) Fishing grounds b) Land Community Assets Livelihood a) Injury b) Lands c) Livestock a) Road a) Agriculture b) Damage to c) Pasturelands d) Means of b) Bridge/Passageways b) Animal husbandry property d) House livelihood c)Power/Telephone c) Beekeeping c) Damage to e) Commercial site e) Other Lines d) Small scale trade livestock f) Other d) Water sources, e) Other d) Other canals and water infrastructure for irrigation and animals e) Drinking f) Sewerage System g) Other 6. Incidents 7. Resettlement 8.Employment 9. Construction Camp 10. Other Regarding Process and and Community (Specify Expropriation and (Specify) Recruitment Relations Compensation (Specify) a) Nuisance from dust (Specify) b) Nuisance from c) Vibrations due to explosions d) Misconduct of the project personal/worker e) Complaint follow up f) Other 8b: Agreed Solutions Format Date: Grievance Number Copies to forward to: Name of the Recorder (Original)-Receiver (Copy) responsible: – Household & business Resettlement Solution Remarks
Annex 8: Grievance Redress Forms Annex 8a. Sample Grievance Redress Form and Agreed Resolution Format Grievance Form Grievance Number: Copies to forward to: Name of the Recorder; (Original)-Receiver Party: LG & Community: (Copy)- Responsible Date: Information About Grievance Define The INFORMATION THE COMPLAINANT Forms of Receipt: □ Community/Information Meetings □ Mail □ Informal □ Other Name Phone Line Village/ Govt. Area Signature of Complainant and Date DETAILS OF GRIEVANCE (addition to list could be made as appropriate) 1. Access to Land and Resources a) Fishing grounds b) Lands c) Pasturelands d) House e) Commercial site f) Other 2. Damage to a) House b) Land c) Livestock d) Means of livelihood e) Other 3. Damage to Infrastructure or Community Assets a) Road b) Bridge/Passageways c)Power/Telephone Lines d) Water sources, canals and water infrastructure for irrigation and animals e) Drinking f) Sewerage System g) Other 4. Decrease or Loss of Livelihood a) Agriculture b) Animal husbandry c) Beekeeping d) Small scale trade e) Other 5. Traffic Accident a) Injury b) Damage to property c) Damage to livestock d) Other 6. Incidents Regarding Expropriation and Compensation (Specify) 7. Resettlement Process (Specify) 8.Employment and Recruitment (Specify) 9. Construction Camp and Community Relations a) Nuisance from dust b) Nuisance from c) Vibrations due to explosions d) Misconduct of the project personal/worker e) Complaint follow up f) Other 10. Other (Specify 8b: Agreed Solutions Format Date: Grievance Number Copies to forward to: Name of the Recorder (Original)-Receiver (Copy) – responsible: Household & business Resettlement Solution Remarks
RP12250RP0P124064B0AFR0RPF0P124905.docx