Complaint or report form for alleged sexual harassment in the university community

Complaint or report form for alleged sexual harassment in the university community

- 2024

 

Secretary of Education of the University of Piura

Through this document, I am writing to you in order to file a complaint or report for sexual harassment, identifying the harasser, clearly describing the events and detailing the evidence, if any, that will assist in proving the acts of sexual harassment; as well as requesting protective measures, as stipulated in Law 27942 and its Regulations, approved by Supreme Decree 014-2019-MIMP.

1. Data of the victim of acts of sexual harassment:

Full name
Full name
Names
Surnames

2. Details of the person against whom the complaint or report is filed:

Full name
Full name
Names
Surnames
Relationship with the affected person

3. Details of the person making the complaint or report:
(In case the victim is not the one who files the complaint)

Full name
Full name
Names
Surnames

4. Details of the facts that are the subject of the complaint or report

(Specifying circumstances, period, place/s, author/s, participants, educational, social or psychological consequences, among others.)

5. Evidence offered or collected that allows verification of acts of sexual harassment

Maximum upload size: 3.15MB

To present witnesses:

I request that protective measures be guaranteed for the witness(es) offered in order to avoid retaliation after the investigation procedure has been completed, in accordance with Law 27942, Law on the Prevention and Punishment of Sexual Harassment and its Regulations approved by Supreme Decree 014-2019-MIMP.

Witness 1

Full name
Full name
Names
Surnames

Witness 2

Full name
Full name
Names
Surnames

Witness 3

Full name
Full name
Names
Surnames

6. Protection measures for the victim

I request that the following protection measures be granted to me:

For the reasons stated above, I request that this complaint be processed in accordance with the procedure established in the Law on the Prevention and Punishment of Sexual Harassment, Law 27942 and its Regulations (DS 014-2019-MIMP).

Personal data protection

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