1.Details and Location Of Complainant
Complaint By	Select Complaint Type * Worker Citizen NGO VIP Media
Complaint Source	Select Complaint Source E-mail Written Complaint Fax Telephone SMS Newspaper
State	GOA
District*	Select District NORTH GOA SOUTH GOA
Block	Select Block
Panchayat	Select Panchayat
Complainant Name *
Name of Father/Husband *
Complainant Address *
Complainant Email
Phone No.	(e.g.011-23381314)
Mobile No.
2.Details and Location Of Complaint
Complaint Against whom*	--Select-- Gram Panchayat Block Panchayat Program officer Zilla Panchayat District Program Coordinator(DPC) Implementing Agency
Implementing Agency name*
State*	Select State ANDAMAN AND NICOBAR ANDHRA PRADESH ARUNACHAL PRADESH ASSAM BIHAR CHANDIGARH CHHATTISGARH DADRA & NAGAR HAVELI DAMAN & DIU GOA GUJARAT HARYANA HIMACHAL PRADESH JAMMU AND KASHMIR JHARKHAND KARNATAKA KERALA LAKSHADWEEP MADHYA PRADESH MAHARASHTRA MANIPUR MEGHALAYA MIZORAM NAGALAND ORISSA PONDICHERRY PUNJAB RAJASTHAN SIKKIM TAMIL NADU TRIPURA UTTAR PRADESH UTTRANCHAL WEST BENGAL
District*	Select District
Block*	Select Block
Panchayat *	Select Panchayat
Complaint Cotegory Registration/Job Card Gram Panchayat not registering Job card not issued Job Card not given to the workers     Demand for work Not registering demand Not giving dated receipt     Work Allocation No work Available Not allocating within 5 K.m. Not giving TA/DA for work site > 5 K.m. Not allocating on time     Payment Delay in payment Partial payment No Payment Improper method used     Work Management Work not created No health facility salary not given to semiskilled/skilled     Unemployment Allowances unemployment Allowances not paid Not accepting application     Measurement No timely measurement Improper Measurement Engineer not coming for measurement Measurement Equipments is not available     Fund fund not available Fund not transferred fund in trasit Banks charging money for transfer of wages     Material not available Hike in price Bad quality of material
Date of Complaint	(DD/MM/YYYY)
Date of occurrrence of event of complaint	(DD/MM/YYYY)
Complaint Description *
3.Evidence submitted by complainant to prove complaint
oral  (Name and other details of witnesses)
Documentry   (Details of document)