Fillable Nysdhr Domestic Workers Complaint Form Fillable (New York)

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Nysdhr Domestic Workers Complaint Form Fillable (New York)

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1
Instructions
Domestic Workers Employment Harassment Complaint Form
Instructions
1) Please fill out this form, answering all of the questions. If you are filling out the form on a computer, please print out the
form immediately when you are finished. You will 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. Notary services are available at the Division free of
charge. Notary services are also available at many banks, town halls, and law offices. If you have any questions about
notarization, or you are unable to obtain notarization, please contact one of our offices (listed below) for further information.
3) Attach copies of any documents that you think will help the Division investigate your case (emails or text messages with
employer, photos, recordings, police reports, statements from witnesses/therapists, 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 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 need further assistance or require an accommodation for a disability, please call or visit one of our offices,
make an appointment, 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 Office 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 Human Rights Law protects you if you are employed in the home or residence of another person for the
purpose of cleaning, food service, childcare, shopping, driving, or any other domestic service purpose and you
are sexually harassed or harassed because of any of the following characteristics. You are also
protected from any adverse action was taken against, such as termination, because you complained about
harassment.
Age
Creed / Religion (religious membership, belief, practice, or observance; or harassment because you do not have
a religious belief)
Disability (a physical or mental condition)
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)
Marital Status (single, married, separated, divorced, widowed)
Military Status (including military reserves, or you are a veteran)
National Origin (the country where you or your ancestors were born)
Predisposing Genetic Characteristics (information from a genetic test)
Race/Color (because you are Asian, Black, White, mixed race, etc.; includes ethnicity; includes traits historically
associated with race such as hair texture or hairstyle)
Sex (because of your gender, includes sexual stereotyping and pregnancy)
Sexual Orientation (heterosexual, homosexual, bisexual, asexual, whether actual or perceived)
Victim of Domestic Violence (you were, or your child was, a victim of domestic violence)
Retaliation (if you were harassed, or had any other action taken against you such as termination, because you
complained about harassment, filed a discrimination case before, were a witness or helped someone else with a
discrimination case, or opposed or reported unlawful discrimination)
Relationship or Association with a member or members of a protected category listed above
The Division cannot investigate unfair treatment that does not involve sexual harassment or
harassment based on one of the above 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.
Please be sure to fill out the Additional Information pages and provide the name of another person who
does not live with you but will know how to contact you if the Division needs to reach you.
1
Complaint
New York State Division of Human Rights
Domestic Workers Harassment Complaint Form
Although 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 domestic worker under the age of 18.
1. Your contact information:
First Name
Last Name
Street Address/ PO Box
Apt or Floor #:
City
State
Zip Code
If you are filing on behalf of a person under the age of 18 for whom you
have legal authority to act, provide the name of that person:
Relationship:
Date of birth:
2. You are filing a complaint against:
(If you wish to file against the person(s) receiving the services and a placement agency, please file two separate
complaints; use the employment complaint form for the placement agency.)
Person(s) receiving the domestic services:
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.
3. Date of alleged discrimination (must be within one year of filing):
The most recent act of discrimination happened on: ______ _____ ______
month day year
4. Are you currently working for the employer you are filing against?
Yes. Date of hire:
______ _____ _____
month day year
No. Last day of work:
______ _____ _____
month day year
2
Complaint
5. Basis of alleged harassment:
Check ONLY the boxes that you believe were the reasons for the harassment. Please look at page 2 of
“Instructions” for an explanation of each category.
Age
Marital Status
Creed/ Religion
Please specify: _______________
Single
Married
Separated
Divorced
Widowed
Disability
Please specify: _______________
National Origin
Please specify: _______________
Domestic Violence Victim Status
Predisposing Genetic Characteristic
Gender Identity or Expression, Including the
Status of Being Transgender
Race/Color or Ethnicity
Please specify: _______________
Familial Status
Sexual Orientation
Please specify: _______________
Military Status
Sex (includes pregnancy):
Please specify: _______________
Active Duty
Reserves
Veteran
If you believe you were harassed, or any adverse action was taken against, such as termination, because you
complained about harassment, filed or helped someone file a discrimination complaint, participated as a
witness to a discrimination complaint, or opposed or reported unlawful discrimination, check below:
Retaliation: How did you oppose or report discrimination: _____________________________________
If you believe you were harassed because of your relationship or association with a member or members of a
protected category listed above, indicate the relevant category above, and check below.
Relationship or Association
3
Complaint
6. Description 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. You may
also write “see attached” and attach a typed description.
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
Based on the information contained in this form, I charge the above-named Respondent with an unlawful
discriminatory practice, in violation of the New York State Human Rights 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
Subscribed and sworn before me
This day of , 20
____________________________________
Signature of Notary Public
County: Commission expires:
Please 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, Page 1
This page is for the Division’s records and will not be sent to the person(s) whom you are filing against.
1. Contact information
My primary telephone number:
My secondary telephone number:
My email address:
My 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, 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:
Title:_________________________________
Name: __________________________
Relationship to me: _____________________
What did this person witness?
_______________________________________________________________________________
_______________________________________________________________________________
Title:_________________________________
Name: ____________________________
Relationship to me: _____________________
What did this person witness?
_______________________________________________________________________________
_______________________________________________________________________________
Telephone Number: __________________
Telephone Number: _______________
2
Additional Information
Additional Information, Page 2
5. The following information may be useful in the investigation of your complaint. Please note that it is
not necessary for you to have complained about the discrimination before you file a complaint with the
Division.
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:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
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Nysdhr Domestic Workers Complaint Form Fillable (New York)

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Completed 16 July 2020

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