Form ETA 8429 ETA 8429 Complaint

OMB Approval No. 1205-0039
Expiration Date: Sep. 30, 2019

U.S. Department Labor
Employment and Training Administration

For Official Use Only

Complaint/Apparent Violation Form 1
Complaint No.

Date Received

Part I. Complainant’s Information 2

Respondent’s Information 3

1. Name of Complainant (Last, First, Middle Initial)

4. Name of Person, Company, or Agency the Complaint is Made
Against
5. Name of Employer (if different from Part I #4 above) /One-Stop
Office

2a. Permanent Address (No., St., City, State, ZIP Code)
b. Temporary Address (if Appropriate)

3a. Permanent Telephone

(
8.

)

-

6. Address of Employer/One-Stop Office

b. Temporary Telephone

(

)

-

7. Telephone Number of Employer/One-Stop Office

(

)

-

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 Complainant 4

10. Date Signed

/
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
4

For definition of “Respondent” see 20 CFR 651.

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

Part II. For Official Use Only
1. Migrant or Seasonal Farmworker?
Yes
No

4. Issue(s) inv olved in Complaint or Apparent
Violation (“X” Appropriate Box(es)):

2. Complaint or Apparent Violation?
Complaint
Apparent Violation

5. H-2A/Criteria Employer
(“X” Appropriate Box(es)):

Wage Related

Housing

Child Labor

Pesticides

Working Conditions

Health/Safety

Migrant and Seasonal
Agricultural Worker
Protection Act (MSPA)

Disability
Discrimination

U.S./Domestic Worker
H-2A Worker

3. Type of Complaint or Apparent Violation
(“X” Appropriate Box(es)):

Wages

Employment Service Related
Job Order No.
Against Local Employment
Service Office
Against Employer
Alleged Violation of
Employment Service
Regulations

Transportation
Meals

Discrimination Other 5
(Specify)

Housing
Other

_____________________________

_____________

Employment-Related Law

6a. Referrals To Other Agencies (“X” Appropriate Box(es))
WHD. U.S. DOL.
OSHA U.S. D.O.L.
EEOC
Other
b. Follow -Up
Yes

Monthly
Quarterly

No

c.

7. Address of Referral Agency (No., St., City, State,
ZIP Code and Telephone No.)

Next Follow -up Date
/

/

(

)

-

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?

11. Provided other One-Stop Services?

Yes

Yes

No If “No”, explain.

No If “No”, explain.

12a.

Name and Title of Person Receiving Complaint

12b.

12c.

Phone No.

12d.

(

)

-

Office Address (No., St., City, State, ZIP Code)
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 30 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.

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