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"Raise Your Concern With Us"

Affected Individual’s Biographical Information

Full Name or Initials

Gender

Religious, ethnic, or other status or background self-identification

Other

Nationality

Date of Birth

Contact Information

Phone

Current City

State

Postal Code

Email Address

Language(s) of communication

Name of representative on behalf of affected person/family member on behalf of affected person, if applicable

Contact Information of the above, if applicable

Phone

Current City

State

Postal Code

Email Address

EMPLOYMENT INFORMATION

Current Employer Name

Occupation

Work Location

Street

City

Country

Employment Start Date

Employment End Date

Is it in the context of the above/current employment that concerns occurred? If no, please provide information on the employment situation that led to challenges for individual

NEEDS & CONSIDERATIONS

Do you have any safety, security or other concerns you would like to discuss or clarify with us at this stage? Please describe or ask question below

Is there any mental or physical impairment or disability we should be aware of?

What type of assistance is needed and/or wanted primarily

Others

NATURE OF CONCERN

Date range of events leading to concern raised here

Location of events leading to concern raised here

Issue

Others

Short summary (Please try to follow order of events since the beginning)

Has this been shared, or raised with anybody else with the aim to seek help or reparation? If yes, specify who and when, and if anything happened since sharing

Is the person(s) involved and responsible for this concern known?YesNoUnsurePartially

Have you faced any of the following? (Check all that apply)You work long hours but are paid much less than the legal minimum/pay is too low.Your boss said he will pay later, but never did or still has not and you have no possibility to complain, or fear to complain.You are promised a good job before you travel. But when you arrive, the contract is different: the pay is lower and the work is harder.You sign a paper in a language you don’t speak. Later, you learn it says something else. In other words, your rights and salary are not what you were told.You work with dangerous tools or chemicals, but your boss doesn’t give you gloves, masks, or other necessary protection.You get hurt or feel very sick at work, but your boss says you must keep working or you will lose your job.You give your passport to your boss when you start working, but they don’t give it back, and you can’t leave or travel freely.You are told to hand over your identity document or card “for safekeeping,” but then you are not allowed to see it or use it when you need it.You want to stop working or leave the job, but your boss says you can’t, or threatens to punish you if you tryYou are forced to work because you’re scared since your boss says you’ll lose your home, be reported to the police, or hurt if you refuse.You are often shouted at, called names, or treated badly at work because you are from another country, look or speak different than them.Someone at work touches you without permission or makes you feel unsafe with words or actions but you are scared to speak up or cannot for other reasons.You live with many people in one small room. It is dirty, has no proper bathroom, and feels unsafe, or you cannot eat or keep clean food.Your housing has no heating in winter, no clean water, or broken toilets and you get sick or injured but your boss still makes you stay there.You are told you cannot leave your home or worker housing without permission, even on your day off.Someone controls where you go, checks your phone, or follows you to stop you from meeting others or asking for help in certain or all situations.You are treated badly, but you are too scared to go to the police because you don’t have papers or fear losing your job.You try to get legal help, but no one responds to you, and/or explains your rights, and no one speaks your language, so you don’t know what to do.Other

Preferred Mode of Communication (Tick the box and add information if not shared yet)PhoneEmailWhatsAppOther

Phone

Email Address

CONSENT & AUTHORIZATION FOR NEXT STEP

Does the affected person consent to this report being sent to our internal organisation for evaluation and so as to understand how we can support the person looking for help?YES

If not, is the caller/person raising concern authorized to act on their behalf? And do they consent to this report being sent to our internal organisation for evaluation and so as to understand how we can support the person looking for help?YES

Can we store, discuss and share, internally only, with our organisation members to evaluate and understand as best as we can?YES

Do you understand that your name, and any personal information, can be requested from this stage onwards to be kept private and confidential when discussing and sharing internally?YES

If desired, what personal information is wished to be kept private and confidential when sharing internally with expert members of our organisation?

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