In order to help businesses stay compliant with regulations, the Occupational Safety and Health Administration (OSHA) has developed a form called Deod 834. This form is used to report any incidents that have occurred in the workplace, and it's mandatory for all businesses to complete this form whenever an incident occurs. By completing Deod 834, businesses can ensure that they are in compliance with OSHA regulations and avoid any penalties. In this blog post, we'll provide a brief overview of what Deod 834 is and how to complete it. Stay safe!
| Question | Answer |
|---|---|
| Form Name | Deod 834 Form |
| Form Length | 4 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 1 min |
| Other names | H-2A, SSN, ny state labor board albany ny, New_York |
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:
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: (____)_________
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. |
DEOD 834 (12/18) |
Page 1 of 4 |
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. |
DEOD 834 (12/18) |
Page 2 of 4 |
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.
DEOD 834 (12/18) |
Page 3 of 4 |
This page is for official use only.
Complaint Number: ________________
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. |
US domestic 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: _____________
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) |
Page 4 of 4 |