POSH operational template
Complaint intake form
A controlled starting format for adaptation to the establishment, applicable rules and matter facts.
Use with care: Do not treat this template as legal advice or as a substitute for the Act, Rules, State requirements, service rules or procedural fairness.
CONFIDENTIAL - STATUTORY COMPLAINT INTAKE
1. Aggrieved woman's name and safe contact method:
2. Workplace / location / employing or host entity:
3. Respondent name and relationship to workplace:
4. Incident date(s), time(s) and place/digital channel:
5. Description of unwelcome conduct and surrounding circumstances:
6. Witnesses and their contact details, if known:
7. Documents/electronic records attached or requiring preservation:
8. Last incident date and limitation note:
9. Assistance required to put complaint in writing:
10. Immediate safety or interim-relief request:
11. Request for conciliation, if any (optional and complainant-led):
12. Police/legal assistance requested, if any:
13. Preferred secure communication arrangements:
Signature / confirmation and date: