Form ETA 8429 ETA 8429 Complaint Form

One Stop Career Center (OSCC) Complaint/ U.S. Department of Labor

Referral Record Employment and Training Administration

For OSCC Use Only OMB Approval No. 1205-0039 Expiration Date: 10/31/2015

Complaint No.

Date Received

Part I. Complainant’s Information				Respondent’s Information
1. Name of Complainant (Last, First, Middle Initial)      				4. Name of Person Complaint Made Against      
2a. Permanent Address (No., St., City, State, ZIP Code)      				5. Name of Employer/OSCC Office      
b. Temporary Address (if Appropriate)      				6. Address of Employer/OSCC Office      
3a. Permanent Telephone (   )     -     	b. Temporary Telephone (   )     -     					7. Telephone Number of Employer/OSCC Office (   )     -     
8. Description of Complaint (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 Complainant			10. Date Signed   /  /    
Part II. For OSCC Use Only
1. Migrant or Seasonal Farmworker? Yes No 2. Type of Complaint (“X” Appropriate Box(es)) Job Service Related Job Order No.    Against Job Service Against Employer Alleged Violation of WIA Regulations Alleged Violation of Employment Law(s) Non-Job Service Related			If non-Job Service related, does Complaint concern laws enforced by U.S. Employment Standards Administration (Wage and Hour) or OSHA? Yes No 4. Kind of complaint (“X” Appropriate Box(es)) Wage Related Housing Child Labor Pesticides Working Conditions Health/Safety Migrant and Season Disability Agricultural Worker Discrimination Protection Act (MSPA) Discrimination* Other (Specify)      						5. H-2a/Criteria Employer U.S./Domestic Worker H-2a Worker Wages Transportation Meals Housing Other      
6. *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.
7a. Referrals To Other Agencies (“X” one) Wage & Hour ESA/U.S. DOL. OSHA Other      					8. Address of Referral Agency (No., St., City, State, ZIP Code and Telephone No.)               (   )     -      
b. Follow-Up (“X” one) Monthly Yes No Quarterly		c. Follow-up Date   /  /    
9. Comments (If additional space is needed, use separate sheet of paper) Provide OSCC Services? Yes No If “No”, explain.      
10a. Name and Title of Person Receiving Complaint      							11. Office Address (No., St., City, State, ZIP Code)      
b. Phone No. (   )     -     							12a. Signature			b. 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, Migrant and Seasonal Farmworker Program, Room S4209, 200 Constitution Avenue, NW, Washington, DC 20210.

ETA 8429

Revised 07/15/2009

Expiration Date: 10/31/2015