NYS DHR | Complaint Form

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 do you believe discriminated against you?

This may be a company or other entity. If you wish to report discrimination against multiple companies or other entities, you must complete a separate report for each one.

Name of Entity *

Street Address *

City *

State *

Zip Code * 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.

Date of the most recent act of alleged discrimination * mm/dd/yyyy format.

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 discrimination do you believe you experienced?

Describe each act of discrimination that you believe you experienced. Include dates, names of people involved, and other details for each act of discrimination. You must explain why you think these acts were discriminatory and how these acts are connected to the protected class bases (e.g., race, color, sex, disability, etc.) you selected previously.

Description of alleged discrimination *

5000 characters remaining

How were other people treated compared to you?

Please answer the following questions:

Were other people treated the same as you? * If so, please tell us their name, what they experienced, including dates if known, and their protected characteristics (e.g., age, race, disability, national origin or ancestry, religion, etc.)

1250 characters remaining

Were other people treated better than you? * If so, please tell us their name, what they experienced including dates if known, and their protected characteristics (e.g., age, race, disability, national origin or ancestry, religion, etc.)

1250 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

Credit

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.

Who do you believe discriminated against you?

This may be a company or other entity. If you wish to report discrimination against multiple companies or other entities, you must complete a separate report for each one.

Do you require an accommodation?

If you require accommodation, check all that apply.

Options

What was the basis for the alleged discrimination?

Select at least one reason why you believe you experienced discrimination. *

What discrimination do you believe you experienced?

How were other people treated compared to you?

Please answer the following questions:

Declaration

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