🛡️ Safe Reporting — HR & Director

Sexual Harassment Report

This form is strictly confidential. Your report goes only to the HR Director and Hospital Director. No retaliation of any kind will be tolerated. You are protected by hospital policy and Ethiopian Labour Law.

You may remain anonymous. Providing your name and contact is optional but helps with follow-up. WCSH has a zero-tolerance policy on sexual harassment.

Your Information (Optional)

Your Name

Your Contact Number

Your Department / Role

Incident Details

* Type of Sexual Harassment

Verbal — inappropriate comments, sexual jokes or remarks Non-verbal — suggestive gestures, staring, or displaying explicit images Physical — unwanted touching, groping, or physical contact Quid pro quo — job benefits or threats linked to sexual favours Digital — unwanted sexual messages, emails, or images via phone/social media Patient or visitor perpetrated — inappropriate behaviour from patient/visitor Other form of sexual harassment

* Date(s) of Incident

* Location / Department where it occurred

About the Person Responsible

Relationship of the perpetrator to you

Supervisor / Manager Colleague (same level) Junior staff / subordinate Patient or patient's family member Visitor / contractor Unknown person Prefer not to say

Department / Role of perpetrator (if known)

Description & Impact

* Has this happened more than once?

Yes — ongoing or repeated No — single incident

* Detailed Description of What Happened

Impact on you (work and wellbeing)

Difficulty performing job duties Anxiety, stress or fear at work Avoiding certain places or the perpetrator Physical symptoms (sleep loss, headaches, appetite change) Other impact

Prior Actions Taken

Did you tell the perpetrator their behaviour was unwelcome?

Yes No I was afraid to

Have you reported this to anyone before?

Yes No

Are there any witnesses?

Desired Outcome & Support

What outcome are you hoping for?

The behaviour to stop immediately Formal disciplinary action against the perpetrator Transfer or separation from the perpetrator Access to counseling or psychological support Awareness training for the team Other outcome

Are you willing to be contacted for follow-up?

Yes — please contact me No — keep anonymous

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Your Confidential Reference Number

Keep this number safe. Only the HR Director and Hospital Director can access your report.

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