📄 Template provided by Embar Legal Advocates, Mysore — PoSH Advisory · shebox.in
For the complainant's use — submit to your organisation's IC Presiding Officer in confidence.

Complaint of Sexual Harassment
To the Internal Committee
Under the Sexual Harassment of Women at Workplace
(Prevention, Prohibition and Redressal) Act, 2013

Date:  

To,
The Presiding Officer,
Internal Committee,
[Name of Organisation]

Part I — Details of the Complainant

Full Name: 
Employee ID / Designation: 
Department / Team: 
Contact Number: 
Email Address: 
Work Location: 
Confidentiality: Under Section 16 of the PoSH Act 2013, the IC is bound to keep the identity of the complainant confidential. Your complaint will not be shared with anyone outside the IC without your consent except for the purpose of inquiry.

Part II — Details of the Respondent

Name of Respondent: 
Designation / Role: 
Department / Team: 
Relationship to Complainant: 

(e.g., supervisor, colleague, client, third party, vendor, contractor)

Part III — Nature of Conduct Complained Of

Please tick all that apply (as defined under Section 2(n) of the PoSH Act 2013):

Physical contact or advances of a sexual nature
Demand or request for sexual favours
Sexually coloured remarks (verbal or written)
Showing pornography or sexually explicit material
Any other unwelcome physical, verbal, or non-verbal conduct of a sexual nature
Online / digital harassment (including emails, messages, social media)
Other (specify below):
 

Part IV — Details of the Incident(s)

Date(s) of Incident(s): 
Time (approx.): 
Location(s): 

(e.g., office premises, client site, online / video call, official event, WhatsApp/email)

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Part V — Prior Attempts to Resolve

Have you previously reported this matter to anyone in the organisation?

Yes    No
 
 

Part VI — Relief Sought

Please indicate the relief or action you are seeking (IC may grant interim relief under Section 12 of the Act):

Inquiry into the complaint and appropriate action against respondent
Transfer of respondent (or complainant, as preferred)
Leave of absence during inquiry
Interim restraint on respondent from accessing complainant's work area
Other (specify):
 

Part VII — Declaration

I,  , do hereby solemnly declare that the information provided in this complaint is true and correct to the best of my knowledge and belief. I understand that a false or malicious complaint may result in action against me under Section 14 of the PoSH Act 2013.

I request the Internal Committee to conduct a fair and confidential inquiry into this matter and take appropriate action in accordance with the Act.

Signature of Complainant

Name:  
Date:  
Important: Submit this complaint within 3 months of the date of the last incident, as required under Section 9(1) of the PoSH Act 2013. The IC may, for sufficient cause, extend this by a further 3 months. Delay beyond this may result in your complaint not being entertained.

Template provided by Embar Legal Advocates, Mysore (shebox.in). Not legal advice. Review with a qualified advocate before relying on this document.