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City of Albany Commission on Human Rights City Hall Room 301 Albany, New York 12207 (518) 434-5296 Employment & Public Accommodations Complaint Form The Commission on Human Rights investigates complaints of discrimination based on: • Age (if you are at least 18 years of age) • Creed/ Religion (religious belief, practice, or observance) • Disability (a physical or mental condition) • Marital Status (single, married, separated, divorced, widowed) • Military Status (including military reserves) • National Origin (the country where you or your ancestors were born) • Race/Color (because you are Asian, Black, Indian, White, etc.; includes ethnicity) • Retaliation (if you filed a discrimination case before, or helped someone else with a discrimination case, or reported discrimination due to race, sex, or any other category listed above or below) • Sex (based on the fact that you are a male or female, sexual stereotyping, sexual harassment, or pregnancy discrimination) • Sexual Orientation (heterosexual, homosexual, bisexual asexual, or perceived) • Gender Identity (self image, behavior, appearance or expression which is different from what is traditionally associated with a person’s legal assigned sex at birth) In addition to the complaint areas listed above, the Commission investigates complaints in regard to housing discrimination. If you believe you have been discriminated against in the area of housing, please contact our office to speak directly with our staff: (518) 434-5296. PLEASE NOTICE: In order to file a complaint with the Albany Commission on Human Rights you must reside within the City of Albany or be filing a complaint against an entity within the City of Albany. ---PAGE BREAK--- Employment & Public Accommodations Discrimination Complaint Intake Form CITY OF ALBANY COMMISSION ON HUMAN RIGHTS Internal Complaint Page 1 of 5 Complainant's Name: Address: Telephone: Work location: Date(s) of alleged violation: Respondent’s Name/Location: Job title: Respondent's telephone: Address: Relationship to complainant: Respondent's Name: Job title: Respondent's telephone: Work location: Relationship to complainant: This complaint is in regard to discrimination in: Employment Public Accommodations Please answer the questions in this section only if you were discriminated against in the area of employment. If not, please proceed to the next page. How many employees does the company have? A. 1-3 B. 4-14 C. 15 or more D. 20 or more E. unsure Are you currently working for the company? Yes Date of Hire: What is your job No Last Day of What was your job I was not hired by the company Date of application:__/__/__ ---PAGE BREAK--- Employment & Public Accommodations Discrimination Complaint Intake Form CITY OF ALBANY COMMISSION ON HUMAN RIGHTS Internal Complaint Page 2 of 5 ---PAGE BREAK--- Employment & Public Accommodations Discrimination Complaint Intake Form CITY OF ALBANY COMMISSION ON HUMAN RIGHTS Internal Complaint Page 3 of 5 I was: terminated not hired not promoted harassed suspended sexually harassed constructively discharged demoted not hired due to BFOQ* retaliated against given a poor evaluation not hired due to a disability denied a raise delegated difficult assignments less trained warned denied an office not hired due to prior criminal record subjected to hostile work environment given different terms/conditions of Other employment *Bona fide occupational qualification I believe the basis of this treatment was due to my: Race/Color or Ethnicity Domestic Violence Victim Status (only for National Origin employment) Creed Military Status Marital/Domestic Partner Status Sex Disability Sexual Orientation Retaliation Arrest Record (only for employment) Age (D.O.B. ) Criminal Conviction Record (only for Religion employment) Genetic Predisposition (only for employment) ---PAGE BREAK--- Employment & Public Accommodations Discrimination Complaint Intake Form CITY OF ALBANY COMMISSION ON HUMAN RIGHTS Internal Complaint Page 4 of 5 Description of Discrimination: Please tell us more about each act of discrimination that you provided information about on the previous pages. Please include dates, names of people involved, and explain why you think it was discriminatory. PLEASE TYPE OR PRINT CLEARLY. ---PAGE BREAK--- Employment & Public Accommodations Discrimination Complaint Intake Form CITY OF ALBANY COMMISSION ON HUMAN RIGHTS Internal Complaint Page 5 of 5 Initial the following that apply: I have been advised during the intake process that my claim may be forwarded to the New York State Division of Human Rights. I have received a copy of this complaint summary, which has been signed by both the Equal Employment Opportunity Specialist and me. If any changes are to be made with regards to the statement(s) contained in this complaint form, I will have to initial each change. I understand that statements contained in this complaint may be used in administrative or legal proceedings and that I may be required to testify at such proceedings concerning this matter. I hereby attest that the facts given in this complaint are true and accurate and that I have been advised of the other avenues of appeal/redress: Complainant Signature /Print Name Date EEO Representative Signature/Print Name Date For Administrative Use Only: This complaint has been reviewed and will be forwarded to the appropriate contact at the State of New York Division of Human Rights. This complaint has been reviewed and will not be forwarded to the appropriate contact at the State of New York Division of Human Rights. For further information, or for specific questions, please contact: City of Albany Equal Employment Opportunity & Fair Housing Office City Hall Room 301 Albany, New York 12207 (518) 434-5296 Affirmative Action Officer /Print Name Date