Form NYS DHR, Employment Complaint Form Instructions

Select if the conduct you experienced constitutes sexual harassment—unwelcome sexual comments, touching, visuals, or requests.

Select this option if one ofe the acts of alleged discrimination is that employer refused to hire you.

Select if you received a disciplinary notice or negative performance evaluation that you believe was discriminatory.

Select if the employer denied your request for a reasonable accommodation related to a disability or pregnancy‑related condition.

Select if you experienced sexual harassment—unwelcome sexual conduct that created a hostile work environment.

Select this box if the employer or agency terminated your employment (fired or laid you off) and you believe the decision was discriminatory.

Select if you were suspended from work and you believe that suspension was based on a protected characteristic or retaliation.

Select if the employer refused to provide a schedule change, leave, or other adjustment you needed because you were a victim of domestic violence.

Select if you were harassed, bullied, or intimidated for any reason connected to a protected characteristic you checked earlier.

Select if you were demoted (given a lower‑level position or title) for discriminatory reasons.

Select if, after a lay‑off, the employer failed to recall you while recalling others and you believe that decision was discriminatory.

Select if the employer denied you schedule changes, dress code exceptions, time off, or other reasonable accommodation needed for your religious observances or practices.

Select if a temporary‑help or employment agency treated you differently or refused to place you in jobs for discriminatory reasons.

Select if you were passed over for a promotion or pay raise that you believe you deserved because of discrimination.

Select if you were paid less than co‑workers doing the same job due to a protected characteristic.

Select if you were denied leave (sick, parental, disability, etc.) or other employment benefits and believe the denial was discriminatory.

Select if a licensing body denied or revoked a professional license you needed for work and you believe the decision was discriminatory.

Select if you were denied training or professional development opportunities for discriminatory reasons.

Select if you were assigned worse or different job duties than co‑workers performing the same role because of discrimination.

Select if you encountered a discriminatory job advertisement, application question, or inquiry from the employer or agency.

Select if any act of discrimination occurred other than: Discriminatory advertisement or inquiry or job application;Gave me different or worse job duties than other workers doing the same job;Denied me training; Denied a license by a licensing agency; Denied me leave time or other benefits; Paid me a lower salary than other co-workers doing the same job; Denied me promotion/pay raise; Denied services or treated differently by a temp or employment agency; Denied me an accommodation for my religious practices; Did not call back after lay-off; Demoted me; Harassed or intimidated me on any basis indicated above; Denied me an accommodation for domestic violence; Suspended me; Fired me/laid me off; Sexual harassment; Denied my request for an accommodation for my disability, or pregnancy-related condition; Gave me a disciplinary notice or negative performance review; Refused to hire me

If you checked “Other Act of Discrimination,” briefly describe that other discriminatory action here (e.g., "refused to transfer me to safer location").

Briefly state the specific pregnancy‑related condition you are citing (max 17 characters, e.g., “gestational diab”).

If you checked Sexual Orientation, enter the exact orientation with which you identify (max 17 characters).

Provide the specific race, color, or ethnic group you identify with (max 17 characters, e.g., “Black,” “Latinx”).

If discrimination involved a particular trait associated with race (for example, a hairstyle), name the trait here (max 17 characters).

Type or write your initials to confirm you have read the preceding statements and that the information you provided is true.

Type your full legal name exactly as it appears on your official identification; this serves as your electronic signature on the complaint.

Explain whether other people were treated the same way as you and describe how (include names or titles if known).

Explain whether other people were treated better than you and describe how (include names or titles if known).

Enter your legal first name as it appears on official documents.

Provide your legal middle initial or full middle name as it appears on official documents, if you have one. Leave blank if none.

Type your legal last (family) name.

List the street address or P.O. Box where you receive mail (number, street name, or box number).

If applicable, add apartment, unit, or floor number for your address; otherwise leave blank.

Enter the city associated with your mailing address.

Enter the two‑letter state abbreviation for your address (e.g., NY).

Enter your 5‑digit ZIP Code (add the 4‑digit extension if you know it).

Check this box if the discrimination occurred in a regular paid employment relationship, including paid internships.

Check if you were working as an independent contractor or performing contract work for the respondent when the discrimination occurred.

Select this box if the disputed treatment involved an unpaid volunteer position.

Check if the discriminatory conduct was carried out by or within a labor organization (union).

Check this box if the discrimination took place in an apprentice or training program.

Select if you were hired or placed by a temporary‐staffing or employment agency that engaged in the discriminatory conduct.

Check this box if the matter involves professional or occupational licensing (e.g., denial of license or renewal).

Check here if you did report or complain about the discrimination to someone (for example Human Resources, a supervisor, a government agency, or a union).

Check here if you did NOT report or complain about the discrimination to anyone.

If you answered “Yes,” describe exactly how you complained (who you spoke or wrote to, what you said, how you delivered the complaint, etc.).

Describe what happened after you complained (for example: investigation, no action taken, retaliation, policy changes).

If you did not report the discrimination, explain your reasons (for example: fear of retaliation, no proper channel, belief it would be useless).

Enter the MONTH (two digits) of the date you reported or complained about the discrimination (e.g., ‘03’ for March).

Enter the DAY (two digits) of the date you reported or complained about the discrimination (e.g., ‘07’ for the 7th).

Enter the YEAR (four digits) of the date you reported or complained about the discrimination (e.g., ‘2024’).

Describe the remedy or outcome you want from this complaint (e.g., apology letter, reinstatement, back pay, policy change).

Full name of the person we should contact if we cannot reach you (e.g., relative, friend, attorney).

Enter th telephone number for the emergency/alternate contact person (include area code).

Enter mailing address for the emergency/alternate contact person (street, city, state, ZIP).

Enter the email address for the emergency/alternate contact person.

Describe how the contact person is related to you (e.g., spouse, friend, lawyer).

Check this box if the employer had between 1 and 14 employees at the time the discrimination occurred.

Check this box if the employer had between 15 and 19 employees at the time the discrimination occurred.

Check this box if the employer had 20 or more employees at the time the discrimination occurred.

Check this box if you do not know how many employees the employer has at the time the discrimination occurred.

Check this box if you worked for the respondent as an unpaid intern rather than a paid employee.

Check this box if you were hired by the respondent and still working for the company and then complete the adjacent date fields for your hire date.

Enter the two‑digit month (MM) of your date of hire if you are currently working for this company.

Enter the two‑digit day (DD) of your date of hire if you are currently working for this company.

Enter the four‑digit year (YYYY) of your date of hire if you are currently working for this company.

Provide your current job title/position with the employer you are complaining about (e.g., Sales Associate, Mechanic).

Check this box if you are no longer employed by the respondent and then complete the adjacent fields for your last day of work.

Enter the two‑digit month (MM) of your last day of work.

Enter the two‑digit day (DD) of your last day of work.

Enter the four‑digit year (YYYY) of your last day of work.

If you are no longer employed, enter the job title/position you held when your employment ended.

Check this box if you applied for the job but were never hired by the respondent employer.

Enter the two‑digit month (MM) of the application if you were never hired.

Enter the numeric day (01‑31) of the application if you were never hired.

Enter the four‑digit year (e.g., 2024) of the application if you were never hired.

If never hired selected, state the exact job title or position you applied for (for example "Sales Associate" or "Systems Analyst").

Provide the exact date (MM/DD/YYYY) on which the most recent discriminatory act occurred.

Enter the county (for example, Westchester) or New York City borough (for example, Brooklyn) where the discriminatory act you are complaining about took place.

Provide your full date of birth in MM/DD/YYYY format if you believe you were discriminated because of your age, otherwise leave blank.

Check if one of the reasons you were discriminated was your Predisposing Genetic Characteristic.

Check if you were discriminated against because of a domestic violence victom status.

Select if you were discriminated because of a pregnancy‑related medical condition (for example, gestational diabetes or pre‑eclampsia).

Check if you allege discrimination based on your gender identity or gender expression (e.g., transgender, non‑binary, gender‑nonconforming).

Check if the discrimination was because of your sexual orientation (e.g., gay, lesbian, bisexual, asexual).

Select if discrimination was because of your race, skin color, or ethnic background.

Select if discrimination was based on your sex (male, female, intersex).

Check if you were discriminated against because of a trait historically linked to race, such as natural hair texture or a protective hairstyle.

Check if discrimination occurred because you are pregnant.

Check if you were discriminated against because of a Use of Guide Dog, Hearing Dog, or Service Dog.

Check this box if you are claiming you were discriminated against because of your age.

Check if you believe you were discriminated against because of your familial status.

Check if you believe you were discriminated against because of an arrest record that was sealed or expunged.

Check if the discrimination was based on your military status in general (including past, current, or future service).

Check if you were on active duty at the time and believe that status led to discrimination.

Check if you are a reservist and allege discrimination because of that status.

Check if you are a veteran and allege discrimination connected to your veteran status.

Check if you believe you were discriminated against because of conviction record.

Check if you are alleging discrimination based on your marital status (regardless of what that status is).

Check if the discrimination was based on your creed or religion.

Check if you allege discrimination because of your national origin.

Check if you were discriminated against because of a physical, mental, or medical disability.

Select if your marital status is single and that fact is relevant to your claim.

Select if you are married and believe this led to discrimination.

Select if you are legally separated and believe this led to discrimination.

Select if you are divorced and allege discrimination because of that status.

Select if you are widowed and allege discrimination because of that status.

If you checked Creed/Religion, briefly specify your religion or creed here (e.g., "Jewish", "Muslim").

If you checked National Origin, specify the nation or ethnicity involved (e.g., "Haitian", "Mexican").

If you checked Disability, provide a short description of the disability relevant to your claim (e.g., "hearing impairment").

Enter the full legal name of the employer, worksite, agency, or union You are filing a complaint against.

Provide the street address or P.O. Box of the employer, worksite, agency, or union You are filing a complaint against.

Enter the city where the employer, worksite, agency, or union You are filing a complaint against is located.

Enter the state (two‑letter abbreviation) where the employer, worksite, agency, or union You are filing a complaint against is located.

Enter the ZIP Code for the employer, worksite, agency, or union You are filing a complaint against address.

Type the employer, worksite, agency, or union You are filing a complaint against main telephone number, including area code; add an extension in the "Ext" space if one is required.

State the official job title or position (e.g., Human‑Resources Director, Business Owner) of the first person who discriminated against you.

Write the full legal name of the first person who disciminated against you.

Write the full legal name of the first person who disciminated against you.

State the official job title or position (e.g., Supervisor, HR Manager) of the second person who discriminated against you.

Check this box if you believe you were treated differently after you filed, helped file, participated as a witness to, opposed, or reported a discrimination complaint based on any protected category.

If you checked the “Retaliation” box, enter a clear, concise narrative describing how you opposed or reported discrimination. Include the specific actions you took, relevant dates, and the names or roles of any persons involved. Leave this field blank if you did not check the “Retaliation” box or the narrative wasn't explicitly provided.

Check if you were discriminated against because of your relationship or association with a person in a protected group (e.g., caregiver of a disabled family member, interracial partner).

Provide the city where you are physically located when you sign the complaint.

Provide the state (two‑letter abbreviation such as “NY”) where you are signing the complaint.

Check this box if you need spoken or written interpretation. Specify the language in the field below.

Check this box if you have specific disablity (e.g., sign‑language interpreter, large‑print materials) and you require accomodations for it.

Check this box if you want your contact information kept confidential because you are a victim of domestic violence.

Check this box if you have a special need not listed above and describe it in the space provided.

If you checked the interpretation box, specify the language you need (e.g., Spanish, ASL).

Describe the specific disability for which accommodation is requested.

Describe any other special need you have that is not covered by the options above.

If you are filing this complaint for someone else, type that person’s full name here. Leave blank if you are filing for yourself.

State your relationship to the person on whose behalf you are filing (e.g., parent, attorney, guardian).

State how this witness is connected to you (for example: co‑worker, supervisor, friend, family member).

Briefly describe exactly what discriminatory actions or events the first witness personally saw or heard.

Name of a second witness or other person who can provide information about your complaint.

Provide the second witness’s job title or role at the time of the events (e.g., ‘Sales Manager,’ ‘Union Steward’).

Give the primary contact information for the seocnd witness (phone number or email address).

State how the second witness is connected to you (co‑worker, supervisor, friend, etc.).

Explain what discriminatory events or remarks this second witness personally observed.

Name of a first witness or other person who can provide information about your complaint.

Job title or role of the first witness/person (e.g., co‑worker, supervisor).

Provide any additional contact information for the first witness/person (such as phone number or email).

Enter an alternate or secondary telephone number where the Division can reach you (include area code).

Enter your primary telephone number, including area code.

Enter your date of birth in MM/DD/YYYY format.

Enter the email address you check most often. This will be used for case updates.