ETA 8429 Tracked Changes

U.S. Department Labor

Employment and Training Administration

OMB Approval No. 1205-0039 Expiration Date: Dec. 31, 2018

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: _________________________________________

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 / /

Part II. For Official Use Only

Migrant or Seasonal Farmworker? Yes No Complaint or Apparent Violation Employment Service Related (“X” Appropriate Box(es)) Complaint against the Employer Apparent violation involving the Employer Complaint against the Local Employment Service Office Apparent violation involving the Employment Service Office 2a. Job Order No, if available: _________________________ 3. Complaint or Apparent Violation Employment-Related Law: Yes No

Issue(s) involved in Complaint or Apparent Violation (“X” Appropriate Box(es)): Wage Related Housing Child Labor Pesticides Health/Safety Discrimination Transportation Trafficking [Grab your reader’s attention with a great quote from the document or use this space to emphasize a key point. To place this text box anywhere on the page, just drag it.] Sexual harassment/coercion/assault Other (Specify)____________________

5. If employer is an H-2A/Criteria Employer, is the complainant a: (“X” Appropriate Box(es)): U.S. Worker H-2A Worker

6a. Referrals To Other Agencies (“X” Appropriate Box(es)) WHD. U.S. DOL. OSHA U.S. D.O.L. 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: 9. Complaint resolved at the local level Yes No If “No,” explain* _________________________________________ [Grab your reader’s attention with a great quote from the document or use this space to emphasize a key point. To place this text box anywhere on the page, just drag it.] 10. Apparent violations resolved at the local level Yes No, If “No,” explain*______________________________________ 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.