NYS DHR | Complaint Form | Violation of Conciliation Agreement

Has a party to your Predetermination Conciliation Agreement and Order After Conciliation violated a term of the agreement?

If you previously filed a complaint with the New York State Division of Human Rights, and during the investigation, your complaint was settled with a “Predetermination Conciliation Agreement and Order After Conciliation,” and if a party to the agreement has not complied with the terms of the agreement, you can report that on this form. The Division will investigate and determine whether there has been a violation of the agreement, and take further action as necessary.

You cannot use this form to report a violation of:

a “Stipulation of Settlement” signed prior to, or during, a hearing at the Division
a settlement obtained for you by the Equal Employment Opportunity Commission, or any other anti-discrimination agency
a private settlement of your claims of discrimination, regardless of whether it was in connection with a prior filing with the Division.

However, you can contact the Division to discuss whether the violation of an agreement other than a Predetermination Conciliation Agreement may be a violation of the law in the form of retaliation for your prior complaint, or any other claims or complaints of discrimination you may have made. In that case, you can be assisted in filing a retaliation complaint.

Please feel free to call the Division of Human Rights at 888-392-3644 to discuss your situation prior to reporting the violation.

Who experienced the alleged discrimination?

To report discrimination, you must be at least 18 years old or an emancipated minor, and you must provide us with at least one method to contact you: email address, phone number, address.

Legal First Name *

Legal Middle Initial

Legal Last Name *

Date of Birth * (for the person who experienced the alleged discrimination)

Street Address

City

State

Zip Code 5 digit format.

Email Address (If you are reporting for someone else, enter yours.)

Phone Number (If you are reporting for someone else, enter yours.) 10 digit format.

If you are reporting discrimination for someone else, tell us about you.

Who violated your conciliation agreement?

Provide the information about the party who violated your Predetermination Conciliation Agreement and Order After Conciliation.

Name of Entity *

Street Address *

City *

State *

Zip * 5 digit format.

In what county or borough did the violation take place? *

Email Address

Company Website

Phone Number * 10 digit format.

Fax Number

Provide the first name, last name, and title of individual people who discriminated against you.

When did the party stop complying with a Predetermination Conciliation Agreement and Order After Conciliation? * mm/dd/yyyy format.
If the party never complied, enter the date the agreement was signed.

Do you require an accommodation?

If you require accommodation, check all that apply.

Options

Privacy - if you are, or your minor child is, a victim of domestic violence.

Interpretation - tell us your primary language (Required)

Accommodation for a disability - (Required: Describe your disability and the accommodation you require.)

Other - Write In (Required)

What did the party do that does not comply with the Predetermination Conciliation Agreement?

Please include the prior complaint number, date of the Predetermination Conciliation Agreement, dates of activities, names of people involved, and explain how the events or inactions are a violation of the Predetermination Conciliation Agreement. *

5000 characters remaining

Declaration

By submitting this information, I give consent to the Division of Human Rights to assess my discrimination experience and help me file a complaint if possible. I also confirm that I haven’t filed any lawsuit or federal, local, or state administrative complaint regarding discriminatory practices based on the same set of facts in this report.

Division of Human Rights

Discrimination Report

Violation of Conciliation Agreement