HUD-4731 Federal Labor Standards Complaint Intake Form

U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT Office of Labor Relations FEDERAL LABOR STANDARDS COMPLAINT INTAKE FORM

HUD FORM 4731 OMB Approval Number 2501-0018 (Exp. 06/30/2007)

Name of complainant      

Social Security Number      

Current address of complainant (Street/City/State/Zip Code)                        

Permanent address, if different from current address                        

Telephone (including area code) (Home/Cell/Other)                  

E-Mail address            

Project name, location and contract/project number                  

Prime contractor company name                  

Employer (company) name            

Employer: name of owner/responsible party            

Employer address                        

Employer: contact information (Telephone/Cell/Other)                        

Check one:

Current employee Former employee Other (specify)

Period employed on the project From:      

To:      

Occupation/job title:            

Duties performed (be specific)                  

Tools used and/or equipment operated                  

Wage Rate: $       per

Hour

Day

Week

Piece

Other (specify):      

Hours usually worked on the project

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

     

     

     

     

     

     

     

Usual start and stop times

Start work time:      

End work time:      

Name of complainant      						Social Security Number      
		Yes	No						Yes	No
Were meal breaks taken? If yes, how long were the breaks? _____________________________								Did the employer keep time records?
Paid Overtime (time and ½) after 40 hours?								Did the complainant keep time records?
Paid for all hours worked?								Does complainant have other personal records (pay stubs, log books, etc.) he/she can provide?
Was/is the complainant an Apprentice?								Were fringe benefits paid?
If fringe benefits were paid, check all that apply:
Cash in lieu of fringe benefits	Life insurance			Pension
Health insurance	Dental insurance			Holiday/Sick/Vacation
Identify other fringe benefits paid            
Names of others affected by the alleged violation(s)                  
Names of others who can verify/attest to the complainant’s allegations                  
Continuation sheets attached Complainant’s personal interview attached Complaint taken by:
Name (print clearly)      					Phone number (including area code) and E-mail address            
Title            					Agency, office            
Signature					Date      

Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining data needed, and completing and reviewing the collection of information. The information is considered sensitive and will not be released without your approval. Provision of this information is voluntary. This agency may not collect this information, and you are not required to complete this form, unless it displays a currently valid Office of Management and Budget (OMB) control number. HUD and local agencies administering HUD-assisted programs must enforce Federal wage and reporting requirements on covered HUD-assisted construction and maintenance work. Enforcement activities include collecting information from laborers and mechanics and other interested parities regarding information about their employment on covered projects.

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HUD-4731 (06/2004) PREVIOUS EDITION IS OBSOLETE