WH-3 Employment Information Form

Zmployment Information Form

U.S. Departmeof Labor

-

Employment Standards,.ainistration
Wage and Hour Division

This report is authorized by Section 11 of the Fair Labor Standards Act. While you are not required to respond, submission
of this information is necessary for the Division to schedule any compliance action. Your identity will be kept confidential
to the maximum extent possible under existing law. Persons are not required to respond to this collection of information
unless it displays a currently valid OMB control number.
1. Person Submitting information
B. Date
4. Name (Print first name, middle ~nitlal,and last name)
Mr.

OMB NO. 12154001
Expires: 06-30-200.

1

Miss

D.

C. Telephone number:

Mrs.

Home:

Ms.

Work:

Address: (Number, Street, Apt. No.)

(City, County, State, Zip Code)

E.

Check one of these boxes
Other

Former employee
of establishment

Present employee
of establishment

(Specify: relative, union, etc)

2. Establishment lnformation
A.

B. Telephone Number

Name of estabiishmenVName of Contact and Title

C. Address of establishment: (Number, Street)

(City, County, State, Zip Code)

D.

I

Estimate number of employees

E Does the flm have branches?

Yes

[7

No

[7 Don't know

If "Yes", name one or two locations:
I

F. Sector: (Select One)

[7 Public agency

Private forprofit

Private non-profit

Nature of establishment's business: (For example; school, farm, hospital, hotel, restaurant, shoe store, wholesale drugs, manufactures stoves,

- coal mine, construction, trucking, etc.)

G.

If the establishment has a Federal Government or federally assisted contract, check the approprlate box(es).
Furnishes goods

H.

C]Performs construction

Furnishes senrices

Don't Know

Does establishment ship goods to or receive goods from other States?
Yes (describe)

Don't know
8. Employment information (Complete A, El, C, D, E, & F if present or f o m r employee of establishment; otherwise complete F only), complete G
only if a potential violation of the Family and Medical Leave Act)
A. Period employed (month, year)
6. Date of birth if you were younger than 19, at any time
while employed at this establ~shment
From:

I

To:

C.

(If still there, state present)

I
I

Ohre your job title and describe briefly the kind of work you do (or did)

Day
--

year

Frequency of payment (check appropriate box)
Weekly

[7 Bi-Weekly

ethod of payment $
,

(Rate)

E. Enter In the boxes below the hours you usuai
work (or worked) each day and each week (I(

Semi-Monthly

per

Monthly

Other

(Hour, week, month, etc.)

I
I
I
I
I
I
I
I
Check the appropriate box(-) and explain briefly in the space below the employment practices which you believe violate the Wage
and Hour laws. (If you need more space use an additional sheet of paper and attach it to this form.)

Does not pay the minimum wage
(explain below)

Excessive deduction or discharge because of wage garnishrner
(explain below)

~ o e not
s pay proper overtime
(explain below)

Employs minors under minimum age for job, for excessive
hours, or in illegal occupations (explain below)

Does not pay prevailing wage/fringe benefits for
Federal Government or federally assisted COfltraCtS
(explain below)
Approximate date government contract ends

Violation of Family and Medical Leave Act (FMLA)
(complete G below)
Other (explain below)

C] Violation of Migrant and Seasonal Agricultural Worker
Protectlon Act (explain below)

Explanation:

G.

Family and Medical Leave Act (FMLA) Ellglblllty

(I) Number of hours employee worked du;ing 12 months prior to the start of FLMA leave
(ii) Employee works at a location where at least 50 or more employees are employed within 75 miles

Yes

No

(iil) Leave Reason (check one)
Birth of a child

Adoption or foster care placement

Employee's serious health condition

Care for a spouse, child or parent wlth a serious health condition
(~ote:lf you think It would be difficult for us to locate the establbhment or where you live, give dlrectlons or attach map.)

Complaint Taken By:

Public Burden Statement

We estimate that it will take an average of 20 minutes to complete this collection of information, including time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for
reducina this burden. to the U.S. DeDaRrnent of Labor. Administrator, Waae and Hour Division.Room S3502.200 Constitution Avenue. N.W..

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