Deod 834 Form PDF Details

The DEOD 834 form is a crucial document for individuals who wish to file a complaint, including discrimination complaints, with the Division of Equal Opportunity Development, housed under the New York State Department of Labor. Located at the Harriman State Office Campus, this division attends to grievances that may arise against public or private employers, employees, companies, or agencies, advocating for the confidentiality and protection of the complainant's information as mandated by law. With the form accessible on the Department's website, it elaborates on the procedural aspects, from filing complaints within specific time frames—180 days for Workforce Innovation and Opportunity Act recipients and up to a year under Human Rights Law—to the detailed instructions on completing the form for those alleging discrimination. It requires the complainant's detailed information, the particulars of the agency or person the complaint is against, and a clear description of the incident, the nature of the discrimination faced if applicable, and the desired outcome of the complaint. Additionally, it prompts for information regarding any previous filing of the case with relevant authorities, underscoring the importance of transparency and thoroughness in the complaint process. The form also includes provisions for complainants who may need assistance in filling it out and assures auxiliary aids and services for individuals with disabilities, showcasing the Department's commitment to equal opportunity and access for all.

QuestionAnswer
Form NameDeod 834 Form
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesH-2A, SSN, ny state labor board albany ny, New_York

Form Preview Example

Division of Equal Opportunity Development

Harriman State Office Campus

Building 12, Room 540

Albany, NY 12240

www.labor.ny.gov

Complaint Number:

________________

Complaint Form, Including Discrimination Complaints

Use this form to file a complaint, including discrimination complaints, with the Division of Equal Opportunity Development. The complaint may be against: a public or private employer, employee, company, or agency, including the New York State Department of Labor or other individuals or entities

Your name and information will be kept confidential to the fullest extent of the law.

For more inforamtion go to: https://www.labor.ny.gov/equal-opportunity or call: (518) 457-9000 or (888) 469-7365. Call (800) 662-1220 for TTY/TTD. People with Disabilities may use the New York State Relay services.

In NYC, dial 211; in all other parts of the State, dial 711.

Instructions: You must file your complaint against Workforce Innovation and Opportunity Act (WIOA) recipients within 180 days from when the incident happened. Human Rights Law however states that a complaint can be filed within a full year from the date of the occurrence.

For all complaints, please complete numbers 1 through 7 and number 13.

If you feel you have been discriminated against, please complete numbers 1 through 13.

Mail the completed and signed form and any supporting documents to the address above.

Note: The person making the complaint, or their representative (see number 10), must sign and date number 13.

If needed, the person handling your complaint will help you fill out this form.

1.Complainant information (Person making the complaint):

First name: _______________________________ MI: ___ Last name: ____________________________________

Address: _____________________________________________________________________________________

City: _________________________________________________________________ State: ____ Zip: _________

Social Security Number: _ _ _ - _ _ - _ _ _ _ Home phone: (____)_________ Work phone: (____)_________

E-mail address: __________________________________________________________

Are you a New York State Department of Labor employee?

Yes

No

2.Respondent information (Agency, employer, or employee you are complaining about):

Name: _______________________________________________________________________________________

Address: _____________________________________________________________________________________

City: __________________________________________________________________ State: ____ Zip: ________

Phone: (____)_________

3. What is the most convenient time for us to contact you about this complaint? ________________

A.M.

P.M.

4a – 4d. Briefly describe your complaint. Be as clear as possible. If you believe you were discriminated against, please describe how, in detail. Attach additional sheets, if needed. Also, attach any written material relating to your case.

4a. What happened? Please include where it happened.

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

 

Equal Opportunity Employer/Program

 

Auxiliary aids and services are available upon request to individuals with disabilities.

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Complaint Number: ________________

4b. Who was involved? Include witnesses, fellow employees, supervisors or others. Provide name, address and phone number, if known.

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

4c. When did it happen, on what date? ____________________________________________________________

4d. How were you treated differently?

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

5.How would you like this complaint to be resolved?

____________________________________________________________________________________________

____________________________________________________________________________________________

6. Were you offered employment services?

Yes

No

7.Do you feel you have been discriminated against?

Yes (If “Yes,” complete numbers 1 through 13) No (If “No,” skip to number 13)

8. How were you discriminated against? Check all that apply and enter requested information.

Race (specify): _____________________________

Genetic predisposition & carrier status (specify):

 

Color (specify): _____________________________

___________________________________________

Religion (specify): ___________________________

Veteran status (specify): ____________________

National Origin (specify): _____________________

Age (Enter date of birth): ____________________

Sex:

Male

Female

Sexual orientation: _________________________

Arrest & conviction record (specify): _____________

Political affiliation (specify): __________________

Disability (specify): __________________________

Victim of Domestic Violence: _________________

Marital status (specify): ______________________

Reprisal/retaliation (specify): _________________

Citizenship (specify): ________________________

Other (specify): ___________________________

Sexual harassment: _________________________

___________________________________________

9.Why do you think this happened? _________________________________________________________________

____________________________________________________________________________________________

10. Do you have an attorney or other representative for this complaint?

Yes

No

If “Yes,” please enter their information below:

 

 

Name: __________________________________________________________________ Phone: (____)_________

Address: _________________________________ City: _________________________ State:____ Zip:_________

 

Equal Opportunity Employer/Program

 

Auxiliary aids and services are available upon request to individuals with disabilities.

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11. Have you filed a case or complaint about this incident with any of the following?

Complaint Number:

 

US Department of Justice, Civil Rights Division

________________

 

NYS Department of Labor, Division of Equal Opportunity Development

 

US Equal Employment Opportunity Commission

NYS Division of Human Rights

US Department of Labor, Civil Rights Center

Federal or State Court

Other: ____________________________________________________________________________________

12. For each agency checked in number 11, please enter the following information:

Agency: __________________________________

Agency: __________________________________

Date filed: _________________________________

Date filed: _________________________________

Case or docket number: ______________________

Case or docket number: ______________________

Date of trial or hearing: _______________________

Date of trial or hearing: _______________________

Location of agency or court: ___________________

Location of agency or court: ___________________

Name of investigator: ________________________

Name of investigator: ________________________

Status of case: _____________________________

Status of case: _____________________________

Comments: ________________________________

Comments: ________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

Agency: __________________________________

Agency: __________________________________

Date filed: _________________________________

Date filed: _________________________________

Case or docket number: ______________________

Case or docket number: ______________________

Date of trial or hearing: _______________________

Date of trial or hearing: _______________________

Location of agency or court: ___________________

Location of agency or court: ___________________

Name of investigator: ________________________

Name of investigator: ________________________

Status of case: _____________________________

Status of case: _____________________________

Comments: ________________________________

Comments: ________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

13.I certify that the information above is true and accurate to the best of my knowledge.

I authorize the disclosure of this information to enforcement agencies for the investigation of my complaint.

I understand that my identity will be kept confidential to the maximum extent possible consistent with applicable law(s).

Complainant’s Signature or Representative’s Signature (see number 10):

________________________________________________________________________ Date: _____________

Equal Opportunity Employer/Program

Auxiliary aids and services are available upon request to individuals with disabilities.

This is the end of the complaint form. Do not write below this line.

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This page is for official use only.

Complaint Number: ________________

------------------------------ For New York State Department of Labor Staff Only ------------------------------

A.Type of complaint. Check all that apply:

Working conditions

Housing

Wage related Discrimination

Pesticides

Child labor

Health/Safety

Other: ___________________________________

B. ES related?

Yes

No

If “Yes,” Job Order Number: ________________________

Against employment service?

Against employer?

Alleged violation of ES regulations?

Alleged violation of employment laws?

 

MSFW with complaint concerning laws enforced by NYS Labor Standards or OSHA?

C.MSFW?

Yes

No

D. Out of state employer?

Yes

No

E.

H-2A/Criteria employer?

US domestic worker

H-2A worker

Wages

Housing

 

Transportation

Meals

 

Other (specify): ___________________________________________________

F.

Referred to:

NYS EO Officer

ESA

OSHA

NYS Monitor Advocate

 

 

NYS Labor Standards

Other: If “Other,” enter the following information:

 

 

Agency name: ____________________________________________________________ Phone: (____)_________

 

Address: __________________________________ City: _______________________ State: ____ Zip: _________

G. Follow up?

Yes

No If “Yes,”

Monthly

Quarterly Follow up date: _______________________

Comments: ___________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

Complaint received by: ____________________________________ Title: ________________________________

Office: _________________________________________________________________ Phone: (____)_________

Signature: _______________________________________________________________ Date: _____________

------------------------------- For United States Department of Labor Staff Only --------------------------------

H.

CIF received by CRC:

Accepted

Case Number: _________________

Not accepted

Comments: ___________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Received by: _____________________________________________________________

Date: _____________

Signature: _______________________________________________________________

Date: _____________

Equal Opportunity Employer/Program

 

Auxiliary aids and services are available upon request to individuals with disabilities.

DEOD 834 (12/18)

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