Grievance reporting form

Identification *I wish to remain anonymousI would like to identify myself

*Please note that no personalized follow-up can be carried out when a grievance is filed anonymously. In this case, the method of resolution will be communicated through the IBA Implementation Committee (Waswanipi) or the Monitoring Committee (Lebel-sur-Quévillon), as applicable.

Organization/Community/Group (if applicable)

First name *

Last Name *

Mailing Address *

City or town *

Province *

Postal code *

Mobile Number (including area code)*

Home telephone number (including area code)*

At which number can you be reached during the day? *MobileHome

What pronouns would you like us to use to refer to you when handling your grievance? (he, she, they, etc.) *

Email address to which you authorize us to send personal information regarding your grievance *

When filing a grievance, Gold Fields considers that you agree to it sharing your email address with Gold Fields employees: unless the grievance relates to sexual harassment. In all other cases, it is your responsibility to notify Gold Fields if you do not want us to share your email address with the defendant.

Gold Fields recognizes that it has a responsibility to ensure that all persons with individual needs receive the accommodations they need to participate fully and fairly in the grievance resolution process. Do you or your representative need accommodation to participate in the resolution process? YesNo

If yes, in what way(s) can we accommodate you?

Détails of the grievance

Name of the company, organization or association (Gold Fields or one of its subcontractors) involved according to the individual reporting the grievance. *

Where did the situation occur?

City or town

Province or territory

When did the situation take place?

Start date Start time if relevant (24:00 hours)

End date End time if relevant (24:00 hours)

Please describe the situation giving that led to the grievance (location, nature of the impact, person(s) or activity(ies) involved):

Details *

Evidence(s) or supporting document(s)*

I confirm that I have provided accurate, truthful and complete information in this form and that it accurately reflects the situation described. I understand that this declaration is in lieu of a signature.*Yes

* Mandatory fields