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    New York City Housing Authority: EEO CASE NO.

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    Michael Warner
    This document contains a complaint form for allegations of employment discrimination from the New York City Housing Authority. The form collects information about the complainant's identity, the nature of the complaint including the alleged basis for discrimination, details of the alleged discriminatory acts, and the corrective actions sought. It also lists government agencies that address employment discrimination complaints and their contact information.

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    © All Rights Reserved
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    New York City Housing Authority: EEO CASE NO.

    Uploaded by

    Michael Warner
    44 views5 pages
    This document contains a complaint form for allegations of employment discrimination from the New York City Housing Authority. The form collects information about the complainant's identity, the nature of the complaint including the alleged basis for discrimination, details of the alleged discriminatory acts, and the corrective actions sought. It also lists government agencies that address employment discrimination complaints and their contact information.

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    036025-rev052017

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    This document contains a complaint form for allegations of employment discrimination from the New York City Housing Authority. The form collects information about the complainant's identity, the nature of the complaint including the alleged basis for discrimination, details of the alleged discriminatory acts, and the corrective actions sought. It also lists government agencies that address employment discrimination complaints and their contact information.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    44 views5 pages

    New York City Housing Authority: EEO CASE NO.

    Uploaded by

    Michael Warner
    This document contains a complaint form for allegations of employment discrimination from the New York City Housing Authority. The form collects information about the complainant's identity, the nature of the complaint including the alleged basis for discrimination, details of the alleged discriminatory acts, and the corrective actions sought. It also lists government agencies that address employment discrimination complaints and their contact information.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 5

    NEW YORK CITY HOUSING AUTHORITY

    DEPARTMENT OF EQUAL OPPORTUNITY


    OFFICE OF EMPLOYMENT & FAIR HOUSING INVESTIGATIONS
    250 BROADWAY, 3rd FLOOR
    NEW YORK, NEW YORK 10007

    COMPLAINT OF ALLEGED DISCRIMINATION

    EEO CASE NO. ___________

    I. Identity of Complainant
    First Name Last Name Employee ID Number Date

    Title
     Civil Service  Provisional

    Home Address

    Home Telephone

    NYCHA Division or Location

    Your Supervisor’s Name

    Your Office Address Your Office Telephone

    II. Status of Complaint


    Check one:

     This is a request for assistance from the Office of Employment Opportunities in order to conciliate a
    complaint of alleged discrimination and/or retaliation.

     This is a formal complaint of alleged discrimination and/or retaliation.

    III. Jurisdiction

    A. Have you ever filed this complaint before?  YES  NO



    If yes, please check appropriate box to indicate where you filed this complaint of discrimination and/
    or retaliation

     EEOC  NY State Division of Human Rights

     NY City Commission on Human Rights  Other (specify) __________________

    B. Did the incident(s) occur within the last twelve (12) months?  YES  NO

    NYCHA 036.025 (Rev. 04/17) 1


    IV. Nature of Complaint

    A. What is the alleged basis of discrimination? (Check any which apply)

     Age (specify) __________________________  Partnership Status



     Alienage/Citizenship (specify) _____________  Predisposing Genetic Characteristic

     Arrest/Conviction ______________________  Prior Salary History _________________

     Caregiver Status ________________________  Race (specify) _________________________



     Color (specify) _________________________  Religion (specify) ______________________

     Disability (specify) _____________________  Retaliation for filing /opposing /assisting in
    investigation of complaint

     Gender (specify) _______________________  Sexual Harassment

     Marital Status (specify) ___________________  Sexual Orientation

     Military Status  Victim of Domestic Violence, Stalking or Sex
    Offenses

     National Origin (specify) _________________  Unemployment Status

     Other _______________________________________________________________________________

    B. Explain what alleged discriminatory act(s) took place.

    NYCHA 036.025 (Rev. 04/17) 2


    C. Name of person(s) you believe discriminated against you (please give name, title and division of each).

    D. When did the alleged discrimination occur? Please be as specific as possible as to date(s)
    and time(s) of occurrence(s).

    E. Where did it take place? Please be as specific as possible as to the location of alleged discriminatory
    act(s).

    NYCHA 036.025 (Rev. 04/17) 3


    F. Were there witnesses to the alleged discrimination? Please give name(s), title(s) and
    division(s) and telephone number(s) of each witness.

    G. Did you report the alleged discrimination to anyone? If so, please state the name(s), title(s),
    division(s) and telephone number(s) of each person to whom you reported.

    H. What corrective action do you want taken?

    NYCHA 036.025 (Rev. 04/17) 4


    GOVERNMENT AGENCIES WHICH ADDRESS COMPLAINTS OF EMPLOYMENT
    DISCRIMINATION
    Any employee or applicant for employment that believes he or she has experienced discrimination has a right
    to file a formal complaint with the federal, state or local agencies listed below. A person does not give up this
    right when a complaint is filed with the Department of Equal Opportunity. The following federal, state and
    local agencies enforce laws against discrimination:
    NEW YORK CITY COMMISSION ON HUMAN RIGHTS
    22 Reade Street, 18th Floor
    New York, New York 10007
    (212) 306-7560

    NEW YORK STATE DIVISION OF HUMAN RIGHTS


    (MAIN OFFICE – NO COMPLAINTS – INDIVIDUALS WITH COMPLAINTS ARE USUALLY GIVEN ADDRESS/
    TELEPHONE NO. OF NEAREST LOCATION TO INDIVIDUAL)
    1 Fordham Plaza
    Bronx, New York 10458
    (718) 741-8450
    163 West 125th Street, 4th Floor
    New York, New York 10027
    (212) 961-8650/51/52
    55 Hanson Place, Room 304
    Brooklyn, New York 11217
    (718) 722-2856
    175 Fulton Avenue, Suite 211
    Hempstead, New York 11550 (LONG ISLAND)
    (516) 538-1360

    UNITED STATES EQUAL EMPLOYMENT OPPORTUNITY COMMISSION


    New York District Office
    33 Whitehall Street, 11th Floor
    New York, New York 10004
    (212) 336-3620

    Note: There are statutory deadlines for filing complaints with each of the agencies listed above. Employees are advised to contact the
    respective agency where they wish to file a complaint in order to find out the applicable deadline.

    I affirm that I have read the complaint of alleged discrimination and that it is true, to the best of my knowledge,
    information and belief. I affirm that I have read the above notice concerning my rights to file a complaint
    with federal, state and local civil rights enforcement agencies.

    Date Complainant’s Signature


    FOR OFFICE USE ONLY
    Date EEO Intake

    Date Interviewed By NJL? Yes No

    NYCHA 036.025 (Rev. 04/17) 5

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