HCSA Grievance Mechanism Complaint Form HCSA Grievance Mechanism_Complaint FormPlease enable JavaScript in your browser to complete this form.1. Name of Grievance Raiser *FirstLast2. Organisation *3. Email *4. Contact Number5. Address *6. For more than one grievance raiser(s), fill in similar details as above in the space provided below.7. Type of Grievance Raiser: *HCSA Executive MemberHCSA MemberNon HCSA MemberIndividual (from business entity, union, non-profit organisation, or stakeholder) Collective (from business entity, union, non-profit organisation, or stakeholder)Third party / Representative (Provide clear evidence in writing on authority to file complaint)8. HCSA Member(s) against whom the Complaint is being raised (“Member Respondent(s)”): *9. HCSA Membership Requirement(s) alleged to be breached: *10. Summary of key facts and chronology of events surrounding the alleged breach of the HCSA Membership Requirement *11. Has the issue been raised with the Member Respondent? *YesNo11.1. If 'Yes', in what form and what was the response provided by the ‘Member Respondent’?12. Does the alleged HCSA Member have a grievance mechanism that allows for a Complaint for the alleged breach? *YesNo If 'Yes', the Grievance Raiser will be required to demonstrate that the Member’s GM was unable to resolve the complaint, or that the resolution proposed by the Member does not have the mutual agreement of the Parties affected by the implementation of the HCSA. Alternatively, the Grievance Raiser may demonstrate that: i) The Member does not have a GM that allows for a Complaint for the alleged breach; ii) The Member does not have a GM that provides for the remedy sought; iii) The Member’s GM is inconsistent with the UNGP requirements for a non-judicial GM and such inconsistency, precludes a just and fair remedy in this case; or iv) The filing of a Complaint before the Member GM would place the Grievance Raiser (or those he/she represents) vulnerable to threats of violence and retaliation.13. Does the complaint’s subject matter duplicate a pending grievance or already examined and settled by the Grievance Panel or by another international Grievance Mechanism. *YesNo13.1 If ‘Yes’, what led the Grievance Raiser to initiate this complaint? Tick the relevant box(es) below and provide further information.The complainant in the other GM is not the directly affected party, but a third party or a non-governmental entity having no mandate from the affected party.The other GM is not mandated to provide the remedy sought by the Grievance Raiser in the pending complaint.The other GM does not have the technical expertise or mandate to analyse and apply the HCSA Requirements or declare breaches or violations similar in nature and scope to those alleged in the Complaint.The procedure followed before the other GM is limited to a general examination of the Member Respondent’s conduct and activities, but there will be no decision on the specific facts that are the subject of the Complaint.None of the above (Please provide an explanation in '13.2').13.2 Explanation to '13.1'.14. Evidence in support of the complaint and its eligibility: *15. Remedy sought from the HCSA Grievance Mechanism: *16. Is there a request for Interim Measures and / or Facilitated Settlement? *YesNo17. Preferred language(s) of the Grievance Raiser(s): *Submit