If more than one person would like to send a complaint to us, each person must complete a separate form. Personal Details Full names Surname Preferred name Title - None -MrMsMrsDrProf Who are you? Who are you? - None -EmployeeStudentOtherOther… Enter other… Employee/Student number Workplace Workplace - None -NWU MahikengPotchestroom CampusNWU VanderbijlparkOtherOther… Enter other… Gender Race Contact details Email address Cellphone number Office number Home number Fax number Complaint Please describe exactly what happened. Include all the information, but be as brief as possible. On what date did this happen? On what date did this happen?: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec On what date did this happen?: Day Day12345678910111213141516171819202122232425262728293031 On what date did this happen?: Year Year1900190119021903190419051906190719081909191019111912191319141915191619171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026202720282029203020312032203320342035203620372038203920402041204220432044204520462047204820492050 Is is still happening? - None -YesNo Where did it happen Do you know which right(s) in the Bill of Rights was/were violated or is/are being violated? - None -YesNo If you know, please state the right(s). Do you know the full name(s), surname(s) of person(s), the association or organisation who violated these rights - None -YesNo If yes, please provide such. Do you have the contact details of those mentioned in the above question, if known? - None -YesNo If yes, please provide such. Email address Cellphone number Office number Home number If the name(s) of the person(s) who violated your human rights are unknown, please provide as much detail as possible about him/her/them, alternatively provide all the information known to you about the person(s) Did anybody see or hear what happened? (Only people who actually saw or heard what happened first hand – witnesses.) - None -YesNo If yes, please provide such. Email address Cellphone number Office number Home number Has this matter been reported to anyone else? - None -YesNo If yes, to whom? Were any steps taken by the person(s), the association or organisation (to whom/which this matter was reported) to resolve this matter? - None -YesNo If yes, please describe the steps What outcome do you propose or expect from this complaint? Please indicate what you would like to achieve with this complaint and the relief sought. Would you be willing to testify against the person(s), the association or organisation that violated your rights? - None -YesNo Please be informed that should you not be willing to testify, the NWU Human Rights Committee may not be able to make a recommendation regarding formal steps to be taken against the person(s), the association or organisation involved. Such recommendations can include mediation and disciplinary action. Do you need an interpreter when attending any proceedings, investigations or possible hearings? - None -YesNo If yes, please indicate the language If yes, please indicate the language - None -AfrikaansEnglishSetswanaSesothoOther… Enter other… Submit Leave this field blank
