Karin Law Form - Andes Iron

1Contact Information

2Type of Report

3Description of the Incident

4Frequency of the Incident

5Witnesses

6Effects of the Incident

7Previous Actions

8Attached Documents

9Labor Inspectorate

10Consent and Final Declaration

Para hacer efectiva su denuncia, le pedimos por favor completar los siguientes datos. Si usted es trabajador o trabajadora de Andes Iron SpA, le informamos que siempre tendrá la opción de presentar su caso en la Dirección del Trabajo correspondiente a su domicilio.

Name(Required)

National ID (RUT)(Required)

Phone Number(Required)

What type of situation would you like to report?

Situación a reportar(Required)

Workplace harassment

Sexual harassment

Workplace violence

Other inappropriate behavior (please specify)

Otros

Description of the incident

Date

DD slash MM slash YYYY

Time (approximate if not known exactly)

Name of the person(s) involved

Detailed description of the incident

Please describe the incident as accurately as possible, including what happened, how, when, and who was present.

Did this incident happen only once, or has it occurred on other occasions?

Cuántas veces ocurrió el incidente

Only once

Happens frequently

Has occurred several times, but sporadically

Were there any witnesses to the incident? (If so, please provide their names and, if possible, contact information or any details that could help identify or locate them)

¿Hubo personas que presenciaron el incidente?

Do you feel that the incident has affected your work, health, or well- being?

¿Siente que el incidente ha afectado su trabajo, salud, bienestar?

Yes

Do you feel that the incident has caused humiliation, harm, or discomfort in the workplace?

¿Siente que el incidente ha tenido un efecto de humillación, menoscabo o malestar en el lugar de trabajo?

Yes

Have you reported this situation to anyone else or any other entity before? (For example: a supervisor, Human Resources, coworkers)

¿Ha informado de esta situación a otra persona o entidad antes?

Yes

Who did he report to?

When was the complaint filed?

What was the response received?

If you have documents, photographs, emails, or other types of evidence to support your report, you may attach them here.

File

Drop files here or

Max. file size: 100 MB.

It's important to remind you that you can file a complaint with the Labor Directorate. Do you prefer that the company conduct an internal investigation?

¿Estás consciente de que puede realizar su denuncia en la Dirección del Trabajo?

Yes, I want an internal investigation.

No, I will file a complaint with the Labor Directorate, and I want them to investigate.

Are you aware that you can file your report with the Labor Inspectorate?

Consent

I declare that the information provided is accurate, and I am aware that the report will be investigated in accordance with the company’s established procedures.

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