Form ES834 "Customer Complaint Information Form" - New York

What Is Form ES834?

This is a legal form that was released by the New York State Department of Labor - a government authority operating within New York. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2019;
  • The latest edition provided by the New York State Department of Labor;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form ES834 by clicking the link below or browse more documents and templates provided by the New York State Department of Labor.

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Download Form ES834 "Customer Complaint Information Form" - New York

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Customer Complaint Information Form
Complaint number:
Instructions: If you have a complaint, please complete this form and submit it to Career Center staff. If this is a discrimination
complaint, you must either submit this form to the Career Center Equal Opportunity officer, or send it to: New York State Department
of Labor, Division of Equal Opportunity Development, State Office Campus, Building 12, Room 540, Albany, NY 12240. If
needed, attach extra pages and any documents about your claim.
1.
Complainant (fill in your information)
First name
MI
Last name
Address
City
State
Zip
Alternative address (if applicable)
SSN (Optional)
Home telephone (
)
Alternate telephone (
)
E-mail address
What are the most convenient time and method for us to contact you about this complaint?
I give my consent to share information regarding this complaint to (list name(s) of family members, friends etc. that can receive
information regarding your complaint):
2.
Respondent (fill in the information for the subject of your complaint)
Agency, business or employee you are making complaint against:
Address
City
State
Zip
Telephone (
)
2a. Is the respondent a Career Center?
Yes
No
If yes, is this complaint regarding
Training
Customer Service
Other
2b. Is the respondent a business?
Yes
No
If yes, were you referred to this business by Career Center staff?
Yes
No If yes, when?
2c. Is the respondent a Farm?
Yes
No
2d. What is your complaint about (check all that apply)?
Wages/unpaid wages
Child Labor
Health and Safety
Working Conditions
Housing
Transportation
Meals
Pesticides
Other
2e. Is your complaint about discrimination?
Yes
No
3.
Briefly describe your complaint. Be as clear as possible. If you believe you were discriminated against, please describe in detail
how this happened.
a. What happened?
b. Who was involved? (Witnesses, fellow employees, supervisors, etc.) Provide name, address and telephone number, if known.
c. When and where did it happen (include date)?
d. If you believe you were treated differently, describe how.
4.
Were you offered employment services?
Yes
No
Customer Complaint Information Form
Complaint number:
Instructions: If you have a complaint, please complete this form and submit it to Career Center staff. If this is a discrimination
complaint, you must either submit this form to the Career Center Equal Opportunity officer, or send it to: New York State Department
of Labor, Division of Equal Opportunity Development, State Office Campus, Building 12, Room 540, Albany, NY 12240. If
needed, attach extra pages and any documents about your claim.
1.
Complainant (fill in your information)
First name
MI
Last name
Address
City
State
Zip
Alternative address (if applicable)
SSN (Optional)
Home telephone (
)
Alternate telephone (
)
E-mail address
What are the most convenient time and method for us to contact you about this complaint?
I give my consent to share information regarding this complaint to (list name(s) of family members, friends etc. that can receive
information regarding your complaint):
2.
Respondent (fill in the information for the subject of your complaint)
Agency, business or employee you are making complaint against:
Address
City
State
Zip
Telephone (
)
2a. Is the respondent a Career Center?
Yes
No
If yes, is this complaint regarding
Training
Customer Service
Other
2b. Is the respondent a business?
Yes
No
If yes, were you referred to this business by Career Center staff?
Yes
No If yes, when?
2c. Is the respondent a Farm?
Yes
No
2d. What is your complaint about (check all that apply)?
Wages/unpaid wages
Child Labor
Health and Safety
Working Conditions
Housing
Transportation
Meals
Pesticides
Other
2e. Is your complaint about discrimination?
Yes
No
3.
Briefly describe your complaint. Be as clear as possible. If you believe you were discriminated against, please describe in detail
how this happened.
a. What happened?
b. Who was involved? (Witnesses, fellow employees, supervisors, etc.) Provide name, address and telephone number, if known.
c. When and where did it happen (include date)?
d. If you believe you were treated differently, describe how.
4.
Were you offered employment services?
Yes
No
5.
How would you like this complaint to be resolved?
If this is a discrimination complaint, fill out numbers 6-10. If this is not a discrimination complaint, go to number 11.
6.
Check all that apply.
Race (specify)
Color (specify)
Religion (specify)
National Origin (specify)
Sex
Male
Female
Arrest & conviction record (specify)
Disability (specify)
Marital status (specify)
Citizenship (specify)
Genetic predisposition & carrier status (specify)
Sexual harassment
Veteran status (specify)
Age (specify date of birth)
/
/
Sexual orientation
Political affiliation (specify)
Victim of Domestic Violence
Reprisal/retaliation (specify)
Other (specify)
7.
Why do you believe these events happened?
8.
Do you have an attorney or other representative for this complaint?
Yes
No
If “Yes,” please fill out the following:
Name
Telephone (
)
Address
City
State
Zip
9.
Have you filed a case or complaint about this incident with any of the following?
US Dept. of Justice, Civil Rights Division
NYS Dept. of Labor, Division of Equal Opportunity Development
US Equal Employment Opportunity Commission
NYS Division of Human rights
US Dept. of Labor, Civil Rights Center
Federal or State Court
Other
10. For each agency checked in number 9, please fill out the following information:
Agency
Date Filed
/
/
Agency
Date Filed
/
/
Case or docket no.
Case or docket no.
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
11. I certify that the information furnished above is true and accurately stated to the best of my knowledge. I authorize the disclosure of
this information to enforcement agencies for the proper investigation of my complaint. I understand that my identity will be kept
confidential to the maximum extent possible consistent with applicable law and a fair determination of my complaint.
Complainant Signature
Date
Staff receiving complaint
(Print Name)
Signature
Date
Career Center
Telephone (
)
Equal Opportunity Employer/Program
ES 834 (07/19)
Auxiliary aids and services are available upon request to individuals with disabilities.
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