Form ETA 8429 ETA 8429 Complaint Form

Migrant and Seasonal Farmworker Monitoring Report and Complaint/Apparent Violation Form

ETA 8429 Complaint Form FINAL 2019-09-12

Job Service Complaint Third Party Disclosure (ETA 8429)

OMB: 1205-0039

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U.S. Department Labor

Employment and Training Administration

OMB Approval No. 1205-0039 Expiration Date: XX/XX/XXXX

For Official Use Only Complaint/Apparent Violation Form1


Complaint/Apparent Violation No.

Date Received




Part I. Contact Information2

Respondent’s Information3




1. Name of Complainant/(Last, First, Middle Initial)4

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

( ) -



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























8b. I hereby give authorization to: _____________________ to act on my behalf regarding this complaint.

Phone #: ___________________Address: _________________________________________



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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 Complainant5

10. Date Signed

/ /


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Part II. For Official Use Only

  1. Migrant or Seasonal Farmworker?

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Yes No

  1. Complaint or Apparent Violation Employment Service Related (“X” Appropriate Box(es))

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Complaint against the Employer

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Apparent violation involving the

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Employer

Complaint against the Local

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Employment Service Office

Apparent violation involving the

Employment Service Office


2a. Job Order No, if available: _________________________

3. Complaint or Apparent Violation Employment-Related Law:

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  1. Issue(s) involved in Complaint or Apparent

Violation (“X” Appropriate Box(es)):

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Wage Related Housing

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Child Labor Pesticides


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Health/Safety Discrimination

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Transportation Trafficking

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Sexual harassment/coercion/assault


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Other (Specify)____________________

5. If employer is an H-2A/Criteria Employer, is the complainant a:

(“X” Appropriate Box):

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U.S. Worker

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H-2A Worker




6a. Referrals To Other Agencies (“X” Appropriate Box(es))

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WHD. U.S. DOL. OSHA U.S. D.O.L.

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EEOC Other

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



( ) -

6b. Next Follow-up Date if complainant is an MSFW

­­­­­­______/_____/______



8. 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:













Shape32 Shape31 9. Complaint resolved at the local level Yes No If “No,” explain* _________________________________________


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10. Apparent violations resolved at the local level Yes No, If “No,” explain*______________________________________


Shape36 Shape35 11. Provided other American Job Center Services Yes No If “No,” explain*______________________________________

*If additional space is needed for explanations, use a separate paper.

12a. Name and Title of Person Receiving Complaint

12b. Office Address (No., St., City, State, ZIP Code)

12c. Phone Number

( )

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 2 hours and 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.

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 651.10.

4 Pursuant to 658.400(d), “A complainant may designate an individual to act as his/her representative.” If the complainant has a designated representative, the name and contact information of the designated representative must be provided in 8b.

5 No signature is required at Part 9 if this form is submitted as an Apparent Violation. If the form is submitted as a complaint and a designated representative is acting on behalf of the complainant, the designated representative must sign here.


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