IPAM - Request form

1. Who is submitting this Request? Please provide your name(s) or the name of your organisation *

2. IPAM is committed to protecting your identity if you fear reprisals. Do you want your name(s) (or the name of your organisation) to be kept confidential throughout this process?

Note. IPAM will share the concerns raised in your request with Bank staff and the Client, but your name and other details that would identify you will not be shared. *

Yes No

a. Why do you require confidentiality? *

3. Do you fear risk of retaliation for sharing your concerns with IPAM? *

Yes No

a. Please provide details. Let us know if this information should be treated confidentially. *

4. Country *

5. Please provide your contact information

a. Telephone number

b. Mobile number

c. Email address *

d. Mailing address *

e. Fax number

How can we best contact you?*

6. Please name or describe the EBRD Project(s) that raises concerns. If you don’t know the Project name, you can include details like the name of the company in charge of the Project, its location, or the activities it is involved in that are affecting you. *

7. What harm do you believe has been caused, or might be caused, by the Project? * Please include details.

8. Are you directly and personally affected by the Project? *

Note: If you are a Representative we will require proof that you have been authorised by the requester to file the Request. All supporting documentation must be sent via email to IPAM (ipam@ebrd.com)

Yes No

a. Are you submitting this Request as a Representative of a person or group affected by the Project?*
Yes No

Please provide the following information about the Project-affected person or group you represent:
Requester name(s):
Requester email address(es):
Requester phone number(s):
Requester mailing address(es):

Note: Written consent signed by the project-affected requesters to act on their behalf in the IPAM process is required. IPAM reserves the right to verify with Requesters that you are authorised to act on their behalf.

b. Are you submitting this Request as an Organisation that is not directly or personally affected by the Project? *
Yes No

i. Are there people living, working or using the land in the Project Area? *
Yes No

a. Please describe your efforts to engage with Project-affected people on the issues you are raising. *

b. What feedback did Project-affected people give you about the Project impacts? *

c. What has prevented Project-affected people from submitting this Request? *

9. Have you ever contacted the EBRD or the EBRD Client to try to raise and voice your concerns? *

Note. IPAM is a 'tool of last resort' so, unless there is fear of retaliation, before submitting a Request to IPAM, you should first voice your concerns:

a) with EBRD staff by sending your concerns to cso@ebrd.com, or
b) with the EBRD Client responsible for the Project.

Note: A written record of your correspondence with the EBRD or the Client in regards to this Request is required.

All supporting documentation must be sent via email to IPAM (ipam@ebrd.com)

Yes No

a. What was the name of the person(s) or department that you contacted?

b. Please describe the efforts you made to raise your concerns with EBRD staff or the Client. How and when did you contact them? (e.g. email, letter, in-person meeting, videoconference, phone)
c. What response did you receive from the EBRD or the Client when you tried to raise your concerns? Please email any records of this contact (e.g. emails, letters, meeting notes)

Reason why you have not contacted the Client or EBRD

10. What do you hope to achieve through the IPAM process?
11. IPAM has two paths for reviewing your concerns.	Path 1– Problem Solving: IPAM can act as a neutral third Party to help find mutually-satisfactory resolutions through flexible, consensus-based problem solving approaches. Path 2 – Compliance Review: IPAM engages with Project-affected people, Bank staff, Clients and others to determine whether the Bank has met the provisions of its Environmental and Social Policy and/or Access to Information Policy. The Compliance function only deals with compliance of the Bank, not that of the Client. At this point, and subject to obtaining more information, what would be your preference? a) I am interested in the Problem Solving option. b) I am interested in the Compliance Review option. c) I am interested in both the Problem Solving and Compliance Review options.
12. Please list the Policy requirements you believe the EBRD has not met on this Project, if you are familiar with the Environmental and Social Policy or Access to Information Policy.
13. Have you submitted any complaints to other organisations in relation to the concerns raised in your Request?
14. Any other information you consider relevant?

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1. Who is submitting this Request? Please provide your name(s) or the name of your organisation *
2. IPAM is committed to protecting your identity if you fear reprisals. Do you want your name(s) (or the name of your organisation) to be kept confidential throughout this process? Note. IPAM will share the concerns raised in your request with Bank staff and the Client, but your name and other details that would identify you will not be shared. *	Yes No a. Why do you require confidentiality? *
3. Do you fear risk of retaliation for sharing your concerns with IPAM? *	Yes No a. Please provide details. Let us know if this information should be treated confidentially. *
4. Country *
5. Please provide your contact information	a. Telephone number b. Mobile number c. Email address * d. Mailing address * e. Fax number How can we best contact you?*
6. Please name or describe the EBRD Project(s) that raises concerns. If you don’t know the Project name, you can include details like the name of the company in charge of the Project, its location, or the activities it is involved in that are affecting you. *
7. What harm do you believe has been caused, or might be caused, by the Project? * Please include details.
8. Are you directly and personally affected by the Project? * Note: If you are a Representative we will require proof that you have been authorised by the requester to file the Request. All supporting documentation must be sent via email to IPAM (ipam@ebrd.com)	Yes No a. Are you submitting this Request as a Representative of a person or group affected by the Project?* Yes No Please provide the following information about the Project-affected person or group you represent: Requester name(s): Requester email address(es): Requester phone number(s): Requester mailing address(es): Note: Written consent signed by the project-affected requesters to act on their behalf in the IPAM process is required. IPAM reserves the right to verify with Requesters that you are authorised to act on their behalf. b. Are you submitting this Request as an Organisation that is not directly or personally affected by the Project? * Yes No i. Are there people living, working or using the land in the Project Area? * Yes No a. Please describe your efforts to engage with Project-affected people on the issues you are raising. * b. What feedback did Project-affected people give you about the Project impacts? * c. What has prevented Project-affected people from submitting this Request? *
9. Have you ever contacted the EBRD or the EBRD Client to try to raise and voice your concerns? * Note. IPAM is a 'tool of last resort' so, unless there is fear of retaliation, before submitting a Request to IPAM, you should first voice your concerns: a) with EBRD staff by sending your concerns to cso@ebrd.com, or b) with the EBRD Client responsible for the Project. Note: A written record of your correspondence with the EBRD or the Client in regards to this Request is required. All supporting documentation must be sent via email to IPAM (ipam@ebrd.com)	Yes No a. What was the name of the person(s) or department that you contacted? b. Please describe the efforts you made to raise your concerns with EBRD staff or the Client. How and when did you contact them? (e.g. email, letter, in-person meeting, videoconference, phone) c. What response did you receive from the EBRD or the Client when you tried to raise your concerns? Please email any records of this contact (e.g. emails, letters, meeting notes) Reason why you have not contacted the Client or EBRD