Form HUD-4731 Federal Labor standards Complaint Intake Form

Federal Labor Standards Questionnaire(s); Complaint Intake Form

HUD-4731

Federal Labor Standards Complaint Intake Form

OMB: 2501-0018

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U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT

Office of Labor Relations

Federal Labor Standards Complaint Intake Form

HUD FORM 4731

OMB Approval No. 2501-0018

(Exp. xx/xx/xxxx)


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.

PREVIOUS EDITION IS OBSOLETE

form HUD-4731 (6/2004)



File Typeapplication/msword
File TitleLABOR STANDARDS_______________________________________________________
AuthorDennis Vearrier
Last Modified ByGuido, Anna P
File Modified2016-11-04
File Created2016-11-04

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