We are conducting a review of federal labor standards compliance on the project named below. We are asking for certain information regarding your employment on this project. Sending this questionnaire to you does not imply that your employer has violated any law.

Please respond to all of the questions listed below. Your responses will be considered confidential and will not be released to anyone without your permission. Your answers should refer only to the time during which you worked on this project. Please return the completed form as soon as possible, using the envelope provided, which needs no postage.

If you have any questions, please call:

Employer

Project name, number and location

1. Your Name

2. Your Job title
3. When did you work on this project?

From: To:	4. Where did you work (job site, shop, etc)?

5. What duties did you perform on this project?

6. What tools did you use (if any) to perform your duties on the project?

7. How were you paid? (hourly wage, salary, piece work, etc.)

8. If your wage was based on piece work, how was your pay determined (i.e., $ per board, per unit, etc.)?

9. What was your hourly wage on this project?

$

10a. Did you receive fringe benefits?

Yes No	10b. If yes, which fringe benefits did you receive?
Vacation

Medical

Pension

Other

Specify:
11. On average, how many hours did you work each week?

12. Did you ever work over 40 hours in a single week?

Yes No	13. If you worked over 40 hours per week, did you receive overtime pay (at least 1½ times your regular rate of pay)?

Yes No	14. If you did not receive overtime pay for overtime hours worked, identify the number of weeks in which overtime was worked and/or total overtime hours

15. Attach copies of check stubs or a record of your hours and pay received

CHECK IF ATTACHED	16. Attach any other comments or statements on separate sheet

CHECK IF ATTACHED
17. Identify other employees (name, address, phone) who worked with you and who could confirm the type of work you performed

18. Identify employees (name, address, phone) you supervised

I affirm that the information provided herein is accurate to the best of my knowledge.
Employee Name (Please print clearly)

Home Phone Number (including area code)
Current address (Include apartment number, if any) (Street/City/State/Zip Code)

Alternate Phone Number(s) (including area code)

Permanent/Alternate Address (if current address is temporary)

Email address
Signature	Date

Disclosure Authorization
I authorize the HUD representative to disclose my name and the information I have submitted to the extent necessary to enforce my rights under the Acts administered by the U.S. Department of Housing and Urban Development.
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 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 contacting laborers and mechanics and requesting information about their employment on covered projects.

U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT

Office of Labor Relations

FEDERAL LABOR STANDARDS QUESTIONNAIRE	HUD FORM 4730

OMB Approval Number 2501- 0018

Exp. 06/30/2007

Page 1 of 2	HUD-4730 (06/2004) PREVIOUS EDITION IS OBSOLETE

LABOR STANDARDS_______________________________________________________

Jade M. Banks

2004-06-21

Jade Banks

HUD