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Community & Environmental Grievance Form

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indiazou
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5 views

Community & Environmental Grievance Form

Uploaded by

indiazou
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 3

COMMUNITY & ENVIRONMENTAL GRIEVANCE FORM

EUROMAX RESOURCES LTD. is committed to providing opportunities for resolution of community and
environmental grievances.

For our Company to adequately address your grievance, please provide us with as many specific details
as possible in this form. Attach pictures or other documents if possible.

All formal complaints must be properly filed out on this form. Please contact the Company Representatives if
you require further assistance with this form.
NAME OF COMPLAINANT: TEL NO:

Age: SEX

M F
Contact Information (Address):

Town/Community:

PART 1: DETAILS OF COMPLAINT / INCIDENT


COMPLAINT SHORT TITLE:

DATE: PLACE OF INCIDENT (Address/Project Site/GPS Coordinates)

BRIEF DESCRIPTION/STATEMENT

If insufficient space please write on a separate sheet, sign, date and attach to this form.

Signature (Complainant) ……………………………………. Date ……………………………………………………………

Signature (CR Staff) ……………………………………. Date ……………………………………………………………


COMMUNITY & ENVIRONMENTAL GRIEVANCE FORM

PART 2: RESPONSE FROM COMPANY


Does the claim proceed?
Yes No
If NO, give reasons:

Name of Person Logging the Incident:

Signature (CR Staff) ……………………………………. Date ……………………………………………………………


Signature (CR Staff) ……………………………………. Date ……………………………………………………………

PART 3: VERIFICATION

PARTICIPANTS’ NAMES FROM DEPARTMENT

________________________________ ___________________________ ___________________________

________________________________ ___________________________ ___________________________

________________________________ ___________________________ ___________________________

Person Responsible for Technical Report ............................................................................................................................

Date of Submittal of Technical Report ............................................................Signature....................................................

Signature (CR Staff) ……………………………………. Date ……………………………………………………………


COMMUNITY & ENVIRONMENTAL GRIEVANCE FORM

PART 4: CORRECTIVE ACTIONS

Specify Corrective Action:

Date of Corrective Action: ……………………………………..

Signature (CR Staff) ……………………………………. Date ……………………………………………………………


ACKNOWLEDGEMENT OF CLOSURE TO GRIEVANCE

Signature (CR Staff) ……………………………………. Date ……………………………………………………………


Signature (CR Staff) ……………………………………. Date ……………………………………………………………

Signature (Company Rep) .………………………………. Date ……………………………………………………………

OTHER RECOURSE TAKEN

If Complainant seeks further action (ADMINISTRATIVE OR LEGAL), please provide details if known.

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