Postal address Informal Other County Signature of Complainant DETAILS OF GRIEVANCE Access to Damage to: Damage to Decrease or Traffic House basic services Infrastructure or loss of Accident Water Land Community livelihood Injury Health Livestock Assets Agriculture Damage Education Means of Road Livestock to livelihood Bridge/Passageways Small scale trade property Other Power/Telephone Other Damage Lines to Water sources livestock (pans, boreholes, Other wells) Drinking water Sewerage system Other Incidents Resettlement Employment and Camp and regarding Process Recruitment and Community (Specify) expropriation (Specify) of contracts Relations and for project Nuisance from Compensation activities (Specify) dust Nuisance from noise Misconduct of the project personal/worker Complaint follow-up 7: GRIEVANCE CLOSE-OUT FORM GRIEVANCE CLOSEOUT FORM Grievance closeout number Define long term action required (if necessary) Compensation required: Y N Verification of Corrective Action and Sign off Corrective Action Steps: Due date: 1 2 3 4 5 Responsible COMPENSATION ACTION AND SIGN OFF This part will be completed and signed by the complainant when he/she receives the compensation or when the file is closed. ___________________________________________________________________
Informal Other Postal address County Signature of Complainant DETAILS OF GRIEVANCE Access to basic services Water Health Education Damage to: House Land Livestock Means of livelihood Other Damage to Infrastructure or Community Assets Road Bridge/Passageways Power/Telephone Lines Water sources (pans, boreholes, wells) Drinking water Sewerage system Other Decrease or loss of livelihood Agriculture Livestock Small scale trade Other Traffic Accident Injury Damage to property Damage to livestock Other Incidents regarding expropriation and Compensation Resettlement Process (Specify) Employment and Recruitment and of contracts for project activities (Specify) Camp and Community Relations Nuisance from dust Nuisance from noise Misconduct of the project personal/worker Complaint follow-up (Specify) 7: GRIEVANCE CLOSE-OUT FORM GRIEVANCE CLOSEOUT FORM Grievance closeout number Define long term action required (if necessary) Compensation required: Y N Verification of Corrective Action and Sign off Corrective Action Steps: Due date: 1 2 3 4 5 Responsible COMPENSATION ACTION AND SIGN OFF This part will be completed and signed by the complainant when he/she receives the compensation or when the file is closed. ___________________________________________________________________
SFG3115-IPP-P161067-Box402893B-PUBLIC-Disclosed-3-3-2017.docx