Form DL1-7013-A and DL1 DL1-7013-A and DL1 Preassessment Forms and Instructions

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Overview

Form A - Preassessment
Form B - Detailed Incident Info
Instructions

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Sheet 1: Form A - Preassessment

SUBMISSION FORM FOR PREASSESSMENT - Form A FAIR PAY and SAFE WORKPLACES

OMB Control Number:

XXXX-A

Expiration Date:

DD/MM/YYYY

* Required Fields

CONTRACTOR INFORMATION

CONTRACTOR IDENTIFIERS

1A. CONTRACTOR LEGAL NAME

2A. CAGE CODE

1B. STREET ADDRESS - LINE 1

2B. DUNS

1C. STREET ADDRESS - LINE 2

1D. CITY

1E. ZIP CODE

1F. STATE

PRIMARY CONTRACTOR REPRESENTATIVE

3A. FIRST NAME

3D. BUSINESS PHONE

3B. LAST NAME

3E. BUSINESS EMAIL

3C. POSITION TITLE

By checking this box, I hereby certify that the information contained within this form, and all corresponding Form XXXX-B, to the best of my knowledge, is true and correctly represents the entity which I am submitting for preassessment.

*4. DATE

Fair Pay and Safe Workplaces Representation

*5A. Are you currently serving, or have you ever served, as a prime contractor on a federal contract with a total contract value (Base plus options years) equal to or greater than $500,000?

YES

If Yes, please answer Question 2A or 2B.

NO

*5B. Are you currently serving, or have you ever served, as a prime contractor on a federal contract with a total contract value (Base plus options years) equal to or greater than $50 million?

YES

If Yes, please answer Question 2A or 2B.

NO

*6. Do you anticpate submitting an offer for a federal solicitation with an estimated contract value of greater than $50 Million to be issued between October 25, 2016 and April 24, 2017 or do you expect to submit an offer on a federal solicitation with an estimated contract value of greater than $500,000 to be issued on or after April 25, 2017? (FAR 52.222-AA)

YES

If Yes, please answer Question 7.

NO

*7A. Has any administrative merits determination, arbitral award or decision, or civil judgment, as defined in guidance issued by the Department of Labor, been rendered against you for violations of any of the labor laws outlined in the Executive Order in the preceding 3-year period or since October 2015 (whichever is shorter)? (FAR 52.222-AA)

YES

NO

*7B. How many administrative merits determinations, arbitral awards or decisions, or civil judgments have been rendered against you for violations of any of the labor laws outlined in the Executive Order in the preceeding 3-year period or since October 2015 (whichever is shorter)?

Please submit as many Form XXXX-B's as the number you indicate in the box.

Paperwork Reduction Act Notice: The Paperwork Reduction Act of 1995 provides that no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. Public reporting burden for this collection of information is estimated to average 1 hour per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Executive Order 13673, as amended (Fair Pay and Safe Workplaces) section 4(b)(ii) authorizes collection of this information. The purpose of this information is to support contractors requesting guidance from the Department of Labor in addressing labor law violations. Completion of this form is voluntary; however, failure to provide the information may result in the Department of Labor's ability to provide accurate guidance. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Office of the Chief Information Officer, Compliance Management Program, 200 Constitution Avenue, N.W., Room N1301, Washington, DC 20210 and reference the OMB Control Number. Note: Please do not return the completed form to this address.

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Form DL1-7013-A

August 2016

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Sheet 2: Form B - Detailed Incident Info

SUBMISSION FORM FOR PREASSESSMENT - Form B FAIR PAY and SAFE WORKPLACES

OMB Control Number:

XXXX-A

Expiration Date:

DD/MM/YYYY

This form is to be used in conjunction with Form XXXX-A, please submit a separate form XXXX-B for each labor law violation.

* Required Fields

CONTRACTOR INFORMATION

CONTRACTOR IDENTIFIERS

1A. CONTRACTOR LEGAL NAME

2A. CAGE CODE

1B. STREET ADDRESS - LINE 1

2B. DUNS

1C. STREET ADDRESS - LINE 2

1D. CITY

1E. ZIP CODE

1F. STATE

Labor Law Violation Details

*3A. TYPE OF VIOLATION

Pick One from Drop Down Menu

*3B. UNIQUE IDENTIFIER

*3C. RELEVANT LABOR LAW

Pick One from Drop Down Menu

*3D. DATE RENDERED

*3E. ENTITY RENDERING JUDGMENT

MITIGATING FACTORS AND/OR REMEDIAL MEASURES

4. Describe your Mitigating Factors and/or Remedial Measures for this Violation (500 Characters)

*5. Are you providing a separate attachment for this violation that provides additional details on your Mitigating Factors and/or Remedial Measures for this Violation?

YES

If Yes, enter the name of the file you are attaching associated to this Violation:

NO

Paperwork Reduction Act Notice: The Paperwork Reduction Act of 1995 provides that no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. Public reporting burden for this collection of information is estimated to average 5.96 hours per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Executive Order 13673, as amended (Fair Pay and Safe Workplaces) section 4(b)(ii) authorizes collection of this information. The purpose of this information is to support contractors requesting guidance from the Department of Labor in addressing labor law violations. Completion of this form is voluntary; however, failure to provide the information may result in the Department of Labor's ability to provide accurate guidance. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Office of the Chief Information Officer, Compliance Management Program, 200 Constitution Avenue, N.W., Room N1301, Washington, DC 20210 and reference the OMB Control Number. Note: Please do not return the completed form to this address.

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Form DL1-7013-B

August 2016

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Sheet 3: Instructions

FORM INSTRUCTIONS FAIR PAY and SAFE WORKPLACES

OMB Control Number:

XXXX-A

Expiration Date:

DD/MM/YYYY

Relevant Labor Laws

Labor Laws relevant to the Fair Pay Safe Workplaces Executive Order and their governing Enforcment Agencies:

A.

Wage and Hour Division (WHD)

1.

The Fair Labor Standards Act

2.

The Migrant and Seasonal Agricultural Worker Protection Act

3.

40 U.S.C. chapter 31, subchapter IV, formerly known as the Davis-Bacon Act

4.

41 U.S.C. chapter 67, formerly known as the Service Contract Act

5.

The Family and Medical Leave Act

6.

E.O. 13658 of February 12, 2014 (Establishing a Minimum Wage for Contractors)

B.

Occupational Safety and Health Administration (OSHA)

1.

The Occupational Safety and Health Act (OSHA) of 1970

2.

OSHA-Approved State Plans

C.

Office of Federal Contract Compliance Programs (OFCCP)

1.

Section 503 of the Rehabilitation Act of 1973

2.

The Vietnam Era Veterans’ Readjustment Assistance Act of 1972 and the Vietnam Era Veterans’ Readjustment Assistance Act of 1974

3.

E.O. 11246 of September 24, 1965 (Equal Employment Opportunity)

D.

National Labor Relations Board (NLRB)

1.

The National Labor Relations Act

E.

Equal Employment Opportunity Commission (EEOC)

1.

Title VII of the Civil Rights Act of 1964

2.

The Americans with Disabilities Act of 1990

3.

The Age Discrimination in Employment Act of 1967

4.

Section 6(d) of the Fair Labor Standards Act (Equal Pay Act)

Contractor Assessment: Preassessment

A "preassessment" process has been implemented to allow contractors to submit for an evaluation that is not associated with a specific procurement contract. Contractor participation in preassessment is voluntary. Preassessment is targeted towards those contractors who have labor law violations, as defined in the EO, and wish to be assessed as a proactive measure prior to allocating resources to prepare a proposal. The assessment process and criteria is identical to preaward. Contractors electing to submit for preassessment must complete this form and submit it to [email protected]. Contractors may be contacted for additional information by government officials as deemed necessary. Results of the preassessment will be emailed to the contractor when the assessment has been completed. The duration of preassessment will vary depending on the size of the contractor and the number of reported labor law violations.

Fields: Pre-Assessment Form A

Prospective contractors that have had an administrative merits determination, arbitral award or decision, or civil judgment, as defined in guidance issued by the Department of Labor, rendered against them within the preceding 3-year period for violations of any of the labor laws and Executive Orders outlined in the Executive Order must submit this form if they wish to initiate preassessment.

Contractor Information:

This section asks for basic contractor information for tracking purposes.

1A. Contractor Legal Name

If registered in the System for Award Management (SAM), the contractor legal name must match the contractor name registered in SAM.

1B. Street Address - Line 1

1C. Street Address - Line 2

1D. City

1E. Zip Code

1F. State

Contractor Identifiers: - CAGE Code - ……

The below contractor identifiers will be used to match preassessment submissions to existing contractor records.

2A. CAGE Code

The Commercial and Government Entity (CAGE) Code is a five-character ID number which is assigned to entities located in the United States by the Defense Logistics Agency’s (DLA’s) Logistics Information Service, under North Atlantic Treaty Organization (NATO) procedures, and used within the Federal Government. CAGE codes are generated during System for Award Management (SAM) after contractor registration.

2B. DUNS

The Data Universal Numbering System (DUNS) number is a unique nine-character identification number provided by the commercial company Dun and Bradstreet (D&B). If you need a DUNS number, one will be provided to you, free of charge. Call D&B at 1-866-705-5711 or access their website at http://fedgov.dnb.com/webform. International registrants may also contact [email protected].

Primary Contractor Representative:

Provide contact information for the resource designated within your entity to serve as the primary point of contact for preassessment inquires. This person may be contacted by DOL representatives for any assessment-related questions and/or requests for additional information.

3A. First Name

3B. Last Name

3C. Position Title

3D. Business Phone

3E. Business Email

*4. Date

Mark the checkbox that indicates you certify that the information you provide is correct, and fill out the date on which you submitted Form A.

Fair Pay and Safe Workplaces Representation

The questions below correspond to the FAR questions that determine whether or not a contractor is to undergo assessment. The following questions are required to be considered for preassessment.

*5A. Are you currently serving, or have you ever served, as a prime contractor on a federal contract with a total contract value (Base plus options years) equal to or greater than $500,000?

Mark your response, either Yes or No. Prime contractors awarded federal business directly from the Federal government and not through another contractor or entity. The prime contractor has full responsivity for the day-to-day management, oversight, and fulfillment of the contract. Estimated contract value includes base contract value plus the value of any option years. For example, if a contract has a base contract value of $1 million, with 4 option years valued at $500,000 each, then the total contract value is $3 million.

*5B. Are you currently serving, or have you ever served, as a prime contractor on a federal contract with a total contract value (Base plus options years) equal to or greater than $50 million?

Mark your response, either Yes or No. Prime contractors awarded federal business directly from the Federal government and not through another contractor or entity. The prime contractor has full responsivity for the day-to-day management, oversight, and fulfillment of the contract. Estimated contract value includes base contract value plus the value of any option years. For example, if a contract has a base contract value of $1 million, with 4 option years valued at $500,000 each, then the total contract value is $3 million.

*6. Do you anticpate submitting an offer for a federal solicitation with an estimated contract value of greater than $50 Million to be issued between October 25, 2016 and April 24, 2017 or do you expect to submit an offer on a federal solicitation with an estimated contract value of greater than $500,000 to be issued on or after April 25, 2017? (FAR 52.222-AA)

Mark your response, either Yes or No. Prime contractors awarded federal business directly from the Federal government and not through another contractor or entity. The prime contractor has full responsivity for the day-to-day management, oversight, and fulfillment of the contract. Estimated contract value includes base contract value plus the value of any option years. For example, if a contract has a base contract value of $1 million, with 4 option years valued at $500,000 each, then the total contract value is $3 million.

*7A. Has any administrative merits determination, arbitral award or decision, or civil judgment, as defined in guidance issued by the Department of Labor, been rendered against you for violations of any of the labor laws outlined in the Executive Order in the preceding 3-year period or since October 2015 (whichever is shorter)? (FAR 52.222-AA)

Mark your response, either Yes or No. For additional guidance, reference the Department of Labor (DOL) Guidance for Executive Order 13673, “Fair Pay and Safe Workplaces” available for download at the following link: http://www.dol.gov/asp/fairpay/2015-12562.pdf

*7B. How many administrative merits determinations, arbitral awards or decisions, or civil judgments have been rendered against you for violations of any of the labor laws outlined in the Executive Order in the preceeding 3-year period or since October 2015 (whichever is shorter)?

Indicate the number of labor law violations for which you will be submitting information. This number is used in validation to ensure DOL has received the proper number of Form XXXX-B's from the contractor.

Fields: Pre-Assessment Form B

This form is to be used in conjunction with Form XXXX-A, please submit a separate form XXXX-B for each labor law violation.

Contractor Information:

This section asks for basic contractor information for tracking purposes.

1A. Contractor Legal Name

If registered in the System for Award Management (SAM), the contractor legal name must match the contractor name registered in SAM.

1B. Street Address - Line 1

1C. Street Address - Line 2

1D. City

1E. Zip Code

1F. State

Contractor Identifiers: - CAGE Code - ……

The below contractor identifiers will be used to match preassessment submissions to existing contractor records.

2A. CAGE Code

The Commercial and Government Entity (CAGE) Code is a five-character ID number which is assigned to entities located in the United States by the Defense Logistics Agency’s (DLA’s) Logistics Information Service, under North Atlantic Treaty Organization (NATO) procedures, and used within the Federal Government. CAGE codes are generated during System for Award Management (SAM) after contractor registration.

2B. DUNS

The Data Universal Numbering System (DUNS) number is a unique nine-character identification number provided by the commercial company Dun and Bradstreet (D&B). If you need a DUNS number, one will be provided to you, free of charge. Call D&B at 1-866-705-5711 or access their website at http://fedgov.dnb.com/webform. International registrants may also contact [email protected].

Labor Law Violation Details:

Input violation details in the requested fields. Details must match documentation provided by the issuing Enforcement Agency.

*3A. Type of Violation

Select from a drop down menu either Administrative Merits Determination, Arbitral Award or Decision or, Civil Judgment. The definitions of these violations are found below. "Administrative Merits Determination" means certain notices or findings of labor law violations issued by an enforcement agency following an investigation. The notices or findings may be final or be subject to appeal or further review. "Arbitral Award or Decision" means an arbitrator or arbitral panel dtermination that a labor law violation occured, or that enjoined or restrained a violation of labor law. It includes one that is not final or is subject ot being confirmed, modified, or vacated by a court, and includes one resulting from private or confidential proceedings. "Civil Judgment" means- 1) A judgment of finding of a civil offense by any court of competent jurisdiction. 2) Any judgment or order entered by any Federal or State court in which the court determined that labor law violation occured, or enjoined or restrained a violation of labow law. It includes a judgment or order that is not final or is subject to appeal. For more information on all Labor Law violation definitions, see the DOL Guidance.

*3B. Unique Identifier

Charge Number, Docket Number or other identifying number given to you by the issuing Enforcement Agency

*3C. Relevant Labor Law

Select from a drop down menu which Labor Law your violation cites.

*3D. Date Rendered

*3E. Entity Rendering Judgment

Enter the name of the court, arbitrator(s), agency, board, or commision rendering the determination or decision.

Mitigating Factors and/or Remedial Measures:

4. Input any mitigating factors and/or extenuating circumstances in free form text. Various factors may mitigate the existence of a Labor Law violation. The Department of Labor respects the fact that most employers endeavor to comply with the Labor Laws. The Department values highly contractors’ good-faith efforts to comply, and it encourages them to report these efforts, including workplace policies that foster compliance. For additional guidance, refer to the DOL Guidance.

*5. Indicate if you plan on submitting any other documents to further explain or provide support for your mitigating factors or remedial measures. If you select option "Yes" please include the name of the file you are submitting.