Form ETA-8429 MSFW Complaint Form

U.S. Department Labor

Employment and Training Administration

OMB Approval No. 1205-0039 Expiration Date: Oct. 31, 2015

For Official Use Only

Complaint/Apparent Violation Form¹

Complaint No.		Date Received
Part I. Complainant’s Information2		Respondent’s Information3
1. Name of Complainant (Last, First, Middle Initial)		4. Name of Person, Company, or Agency the Complaint is Made Against
2a. Permanent Address (No., St., City, State, ZIP Code)		5. Name of Employer (if different from Part I #4 above) /One-Stop Office
b. Temporary Address (if Appropriate)		6. Address of Employer/One-Stop Office
3a. Permanent Telephone ( ) -	b. Temporary Telephone ( ) -		7. Telephone Number of Employer/One-Stop Office ( ) -

8. Description of Complaint or Apparent Violation (If additional space is needed, use separate sheet(s) of paper and attach to this form)

I CERTIFY that the information furnished is true and accurately stated to the best of my knowledge. I AUTHORIZE the disclosure of

Certification this information to other 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.

9. Signature of Complainant4

10. Date Signed / /

Part II. For Official Use Only

Migrant or Seasonal Farmworker? Yes No Complaint or Apparent Violation? Complaint Apparent Violation 3. Type of Complaint or Apparent Violation (“X” Appropriate Box(es)): Employment Service Related Job Order No. Against Local Employment Service Office Against Employer Alleged Violation of Employment Service Regulations Employment-Related Law

Issue(s) involved in Complaint or Apparent Violation (“X” Appropriate Box(es)): Wage Related Housing Child Labor Pesticides Working Conditions Health/Safety Migrant and Seasonal Disability Agricultural Worker Discrimination Protection Act (MSPA) Discrimination Other5 (Specify) _____________________________

5. H-2A/Criteria Employer (“X” Appropriate Box(es)): U.S./Domestic Worker H-2A Worker Wages Transportation Meals Housing Other _____________

6a. Referrals To Other Agencies (“X” Appropriate Box(es)) WHD. U.S. DOL. OSHA U.S. D.O.L. EEOC Other				7. Address of Referral Agency (No., St., City, State, ZIP Code and Telephone No.) ( ) -
b. Follow-Up Monthly			c. Next Follow-up Date / /
Yes No		Quarterly
8. Explanation of Complaint/Apparent Violation (If additional space is needed, use separate sheet of paper) 9. Actions Taken on Complaint/Apparent Violation (If additional space is needed for multiple actions taken, use a separate paper): Action Taken By: __________________________________________________________ On: ______________________ (First and Last Name) (Date) Action Taken: 10. Complaint /Apparent Violation resolved? Yes No If “No”, explain. 11. Provided other One-Stop Services? Yes No If “No”, explain.
12a. Name and Title of Person Receiving Complaint					12b. Office Address (No., St., City, State, ZIP Code)
12c. Phone No. ( ) -					12d. Signature	12e. Date / /

Public Burden Statement

Persons are not required to respond to this collection of information unless it displays a currently valid OMB Control Number. Obligation to reply is required to obtain or retain benefits (44 USC 5301). Public reporting burden for this collection is estimated to average 8 minutes per response, including the time to review instructions, search existing data sources, gather and maintain the data needed, and complete and review the collection of information. Send comments regarding this burden estimate or any other aspect of this collection, including suggestions for reducing this burden, to the U.S. Department of Labor, Employment and Training Administration, Office of Workforce Investment, Room C-4510, 200 Constitution Avenue, NW, Washington, DC 20210.

1 For information regarding complaints that are covered through the Employment Service and Employment-Related Law Complaint System see 20 CFR 658 Subpart E.

2 If the Complaint/Apparent Violation Form is used to submit an Apparent Violation, the name of the Complainant is not necessary and may remain anonymous. Parts 2a and 2b also do not need to be filled out if the form is used for an Apparent Violation.

3 For definition of “Respondent” see 20 CFR 651.

4 No signature is required at Part 9 if this form is submitted as an Apparent Violation.

5 For DISCRIMINATION COMPLAINTS ONLY. Persons wishing to file complaints of discrimination may file either with the State Workforce Agency, or with the Directorate

of Civil Rights (DCR), U. S. Department of Labor, 200 Constitution Avenue, NW, Room N-4123, Washington, D.C. 20210