Fillable Employment Discrimination Complaint Form (Includes Licensing, Contract Work, (New York State)

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Employment Discrimination Complaint Form (Includes Licensing, Contract Work, (New York State)

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1
Instructions
Employment Discrimination Complaint Form
(Includes Licensing, Contract Work, Internships, Volunteer Position, Discrimination by a Union)
Instructions
1) Please fill out the complaint form, answering all of the questions. If you are filling out the form on a computer, please
print it immediately when you are finished. You may not be able to save the completed form. If possible, please
type. If you are filling out the form by hand, please print. Please do not write in the margins or on the back of this
form.
Please note: A delay could occur in the filing and the investigation of your complaint if the form is not filled
out properly or if the information you provide is not legible.
2) After you fill out the form, please have this complaint form notarized. Please contact our office if you have questions
about notarization (see below). Notary services are available at the Division free of charge. If you are unable to come
to one of our offices, and are otherwise unable to obtain notarization, please contact one of our offices for further
information.
3) Attach copies of any documents that you think will help the Division investigate your case (pay stubs, letter of
termination, performance evaluations, disciplinary notices, etc.).
4) Return the complaint form to the office closest to you. See below for the list of office locations. You may return the
complaint by postal mail or personal delivery. You may also email your complaint to complaints@dhr.ny.gov
or fax
it to (718) 741-8322.
5) Keep a copy of your complaint, and copies of any documents that you attach, for your own records.
6) The completed and notarized complaint must be returned to the Division promptly. After the Division accepts your
complaint, this form will be sent to the company or person(s) whom you are charging with discrimination.
Time Limit for Filing
Please note: You must file your complaint within one year of the most recent act of alleged discrimination. If you were
terminated, you must file within one year of the date you were first informed you would be terminated.
If you need further assistance or require an accommodation for a disability, please call one of our offices,
make an appointment for a personal meeting or visit our website at www.dhr.ny.gov/complaint. Interpreter
services are also available at no cost upon request.
NYS Division of Human Rights Offices
Albany
Agency Building 1, 2nd Floor
Empire State Plaza
Albany, New York 12220
Telephone No. (518) 474-2705
Buffalo
Walter J. Mahoney State Office Bldg.
65 Court Street, Suite 506
Buffalo, New York 14202
Telephone No. (716) 847-7632
Office of Sexual Harassment
Issues/Queens
55 Hanson Place, Room 900
Brooklyn, New York 11217
Telephone No. (718) 722-2060
Binghamton
44 Hawley Street, Room 603
Binghamton, New York 13901
Telephone No. (607) 721-8467
Long Island (Nassau)
50 Clinton Street, Suite 301
Hempstead, New York 11550
Telephone No. (516) 539-6848
Rochester
One Monroe Square
259 Monroe Avenue, Suite 308
Rochester, New York 14607
Telephone No. (585) 238-8250
Bronx Central Office
One Fordham Plaza, 4
th
Floor
Bronx, NY 10458
Telephone No. (718) 741-8400
Long Island (Suffolk)
250 Veterans Memorial Highway,
Suite 2B-49
Hauppauge, New York 11788
Telephone No. (631) 952-6434
Syracuse
John J. Hughes State Office Building
333 E. Washington Street, Room 543
Syracuse, New York 13202
Telephone No. (315) 428-4633
Brooklyn
55 Hanson Place, Room 304
Brooklyn, New York 11217
Telephone No. (718) 722-2385
Manhattan
Adam Clayton Powell Jr. State Off. Bldg.
163 West 125th Street, 4
th
Floor
New York, New York 10027
Telephone No. (212) 961-8650
White Plains
7-11 South Broadway, Suite 314
White Plains, New York 10601
Telephone No. (914) 989-3120
2
Instructions
What is Covered by the Human Rights Law?
The Division of Human Rights investigates complaints of employment discrimination based on:
Age (if you are at least 18 years of age; those under 18 are protected for all other characteristics listed below)
Arrest Record (that was resolved in your favor or adjourned in contemplation of dismissal or youthful offender
record or sealed conviction record)
Conviction Record
(only for private employers; against public employers, you must file directly in state court)
Creed / Religion (religious membership, belief, practice, or observance, including sabbath or holy day
observance, or wearing of attire, clothing or facial hair in accordance with your religion; or discrimination because
you do not have a religious belief)
Disability (a physical or mental condition; includes denial of reasonable accommodation)
Victim of Domestic Violence (you or your child was a victim of domestic violence; including reasonable
accommodation in the form of leave time needed because of the domestic violence including medical,
psychological, legal or other services, or for safety)
Familial Status (if you are pregnant, have a child, or are in the process of obtaining custody of a child, or
have a child or children under age 18 in your household)
Gender Identity or Expression (actual or perceived gender-related identity, appearance, behavior, expression,
or other gender-related characteristic regardless of the sex assigned to that person at birth, including, but not
limited to, the status of being transgender; complaints involving the need for accommodation of gender dysphoria
or other related medical condition can also be filed under disability)
Marital Status (single, married, separated, divorced, widowed)
Military Status (including military reserves or being a veteran)
National Origin (the country where you or your ancestors were born)
Predisposing Genetic Characteristics (information from a genetic test)
Pregnancy-Related Condition (a medical condition related to pregnancy or childbirth, including lactation, or
denial of reasonable accommodation of such condition)
Race/Color (because you are Asian, Black, White, etc.; includes ethnicity; includes traits historically associated
with race such as hair texture or hairstyle)
Retaliation (if you filed a discrimination case before, were a witness or helped someone else with a
discrimination case, or opposed or reported discrimination due to category listed on this page)
Sex (because of your gender, includes sexual stereotyping, sexual harassment, pregnancy)
Sexual Orientation (heterosexual, homosexual, bisexual, asexual, whether actual or perceived)
Use of Guide Dog, Hearing Dog, or Service Dog
(use of a professionally trained dog for a disability)
Relationship or Association
(with a member or members of a protected category(ies) listed above)
The Division investigates complaints only if the discrimination is based on one or more of the above reasons. The
Division cannot investigate unfair treatment that does not involve one of these reasons. If you do not see anything
in this list that applies to your situation, please contact the Division of Human Rights to speak to a staff member.
1
Complaint
New York State Division of Human Rights
Employment Complaint Form
Although workers, interns and volunteers of all ages are protected, you must be 18 years or older to file a complaint. A parent,
guardian or other person having legal authority to act in the minor’s interests must file on behalf of a person under the age of 18.
1. Your contact information:
First Name
Middle Initial/Name
Last Name
Street Address/ PO Box
Apt or Floor #:
City
Zip Code
If you are filing on behalf of another, provide the name of that
person:
Date of birth:
Relationship:
2. Regulated Areas: Check the area where the discrimination occurred:
(If you wish to file against multiple entities, for example employer and temp agency, please file a separate complaint
against each.
)
Employment
(including paid internship
)
Internship (unpaid)
Contract Work
(independent contractor, or work for a
contractor)
Volunteer Position
by a Labor Organization
Apprentice Training
by a Temp or Employment Agency
Licensing
3. You are filing a complaint against:
Employer, Worksite, Agency or Union Name
Street Address/ PO Box
City
State
Zip Code
Telephone Number:
( ) Ext.
In what county or borough did the violation take place?
Individual people who discriminated against you:
Name: ____________________________ Title: _____________________________
Name: ____________________________ Title: _____________________________
If you need more space, please list them on a separate piece of paper.
4. Date of alleged discrimination (must be within one year of filing):
The most recent act of discrimination happened on: ______ _____ ______
month day year
5. For employment and internships, how many employees does this company have?
1-14
15-19
20 or more
Don’t know
2
Complaint
6. Are you currently working for this company?
Yes. Date of hire:
______ _____ _____
month day year
What is your position?
No. Last day of work:
______ _____ _____
month day year
What was your position?
I was never hired.
Date of application:
______ _____ _____
month day year
What position did you apply for?
7. Basis of alleged discrimination:
Check ONLY the boxes that you believe were the reasons for discrimination, and fill in specifics only for those
reasons. Please look at page 2 of “Instructions” for an explanation of each type of discrimination.
Age:
Date of Birth: _______________
Familial Status:
Arrest Record
Military Status:
Active Duty
Reserves
Veteran
Conviction Record
Marital Status
Single
Married
Separated
Divorced
Widowed
Creed/ Religion:
Please specify: _______________
National Origin:
Please specify: ________________
Disability:
Please specify: _______________
Predisposing Genetic Characteristic:
Domestic Violence Victim Status
Pregnancy-Related Condition:
Please specify: _______________
Gender Identity or Expression, Including the
Status of Being Transgender
Sexual Orientation:
Please specify: ________________
Race/Color or Ethnicity
:
Please specify: _______________
Sex
:
Please specify: ________________
Specify if the discrimination involved:
Trait historically associated with race such as hair
texture or hairstyle
Pregnancy Sexual Harassment
Use of Guide Dog, Hearing Dog, or Service Dog
If you believe you were treated differently after you filed or helped someone file a discrimination complaint,
participated as a witness to a discrimination complaint, or opposed or reported discrimination due to any
category above, check below:
Retaliation: How did you oppose discrimination: __________________________________________
If you believe you were discriminated against because of your relationship or association with a member or
members of a protected category listed above, indicate the relevant category(ies) above, and check below.
Relationship or association
2
Complaint
8. Acts of alleged discrimination: What did the person/company you are complaining against do? Check all
that apply
Refused to hire me
Gave me a disciplinary
notice or negative
performance review
Denied my request for
an accommodation for
my disability, or
pregnancy-related
condition
Sexual harassment
Fired me/laid me off
Suspended me
Denied me an
accommodation for
domestic violence
Harassed or intimidated
me on any basis indicated
above
Demoted me
Did not call back after
lay-off
Denied me an
accommodation for my
religious practices
Denied services or treated
differently by a temp or
employment agency
Denied me promotion/
pay raise
Paid me a lower salary
than other co-workers
doing the same job
Denied me leave time or
other benefits
Denied a license by a
licensing agency
Denied me training
Gave me different or
worse job duties than
other workers doing the
same job
Discriminatory
advertisement or inquiry
or job application
Other:
3
Complaint
9.
D
escription of alleged discrimination
Tell us more about each act of discrimination that you experienced. Please include dates, names of
people involved, and explain why you think it was discriminatory. TYPE OR PRINT CLEARLY.
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
If you need more space to write, please continue writing on a separate sheet of paper and attach it to the
complaint form. DO NOT WRITE IN THE MARGINS OR ON THE BACK OF THIS FORM.
4
Complaint
Notarization of Complaint
B
ased on the information contained in this form, I charge the herein named respondent(s) with an unlawful
discriminatory practice, in violation of the New York State Human Rights Law.
B
y filing this complaint, I understand that I am also filing my employment complaint with the United States Equal
Employment Opportunity Commission under the Americans With Disabilities Act (covers disability related to
employment), Title VII of the Civil Rights Act of 1964, as amended (covers race, color, religion, national origin,
sex relating to employment), and/or the Age Discrimination in Employment Act, as amended (covers ages 40
years of age or older in employment). This complaint will protect my rights under federal law.
I
hereby authorize the New York State Division of Human Rights to accept this complaint on behalf of the U.S.
Equal Employment Opportunity Commission, subject to the statutory limitations contained in the aforementioned
law.
I have not filed any other civil action, nor do I have an action pending before any administrative agency, under
any state or local law, based upon this same unlawful discriminatory practice.(If you have another action pending
and still wish to file, please contact our office to discuss.)
PLEASE INITIAL __________
I
swear under penalty of perjury that I am the complainant herein; that I have read (or have had read to me) the
foregoing complaint and know the contents of this complaint; and that the foregoing is true and correct, based
on my current knowledge, information, and belief.
_____________________________
Sign your full legal name
S
ubscribed and sworn before me
This day of , 20
____________________________________
Signature of Notary Public
County: Commission expires:
P
lease note: Once this form is completed, notarized, and returned to the New York State Division of
Human Rights, it becomes a legal document and an official complaint with the Division.
1
Additional Information
Additional Information
This page is for the Division’s records and will remain confidential and will not be sent to the company
or person(s) whom you are filing against.
1. Contact Information
My primary telephone number:
( ) -
My secondary telephone number:
( ) -
My email address:
Date of birth:
Contact person: (Someone who does not live with you but will know how to contact you if the Division cannot
reach you)
Name: _______________________________________________
Telephone number: ____________________________________
Address: _____________________________________________
Email address: ________________________________________
Relationship to me: _____________________________________
2. Special Needs
I am in need of:
Interpretation (if so what language?): __________________________________
Accommodations for a disability: ____________________________________
Privacy. Keep my contact information confidential as I am a victim of domestic violence
Other: _________________________________________________________
3. Settlement / Conciliation
To settle this complaint, I would accept: (Explain what you want to happen as a result of this complaint. Do
you want a letter of apology, job offer, return to the job, an end to the harassment, compensation, etc.?)
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
4. Witnesses (information about witnesses may be shared with the parties as necessary for the
investigation)
The following people saw or heard the discrimination and can act as witnesses:
Name: _____________________________
Title:_________________________________
Telephone Number:
_______________
Relationship to me: _____________________
W
hat did this person witness?
_______________________________________________________________________________
______________________________________________________________________________
Name: _____________________________ Title:_________________________________
Telephone Number: _______________
Relationship to me: _____________________
What
did this person witness?
_______________________________________________________________________________
2
Additional Information
Additional Information, Page Two
5. Did you report or complain about the discrimination to someone else?
Yes
No
If yes, how exactly did you complain about the discrimination?
(To whom did you complain?)
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Date you reported or complained about discrimination: ________ _____ _______
month day year
What happened after you complained?
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
If you did not report the discrimination, please explain why:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
6. Were other people treated the same as you? How?
(For example, people who were harassed by the same manager, disciplined or terminated for the same
reasons, did not receive an accommodation for the same reasons, etc.).
If you are complaining about discrimination relating to race, national origin, age, religion, etc. please
describe their races, national origins, religions, etc.
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
7. Were other people treated better than you? How?
(For example, people who were not fired for doing the same thing you were fired for, people who were
doing the same job but making more money, etc.).
If you are complaining about discrimination relating to race, national origin, age, religion, etc. please
describe their races, national origins, religions, etc.
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
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Employment Discrimination Complaint Form (Includes Licensing, Contract Work, (New York State)

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Completed 26 August 2020

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