WH-516 Proposed Revision

Migrant and Seasonal Agricultural Worker Protection Act

U.S. Department of Labor

Wage and Hour Division

Worker Information—Terms and Conditions of Employment

OMB NO: 1235-0002

Expires: 09/30/2026

1. Name of employer:

2. Address of employer: ________________________________________________________________________________________________

3. Worksite location(s) if different than employer’s address: ______________________________________________________________________

4. Approximate period of employment: From To

5. Pay: Hourly Rate $____________ Piece Rate $______ per _______

(Note: Worker must be paid the higher of the hourly rate and the piece rate for each hour worked. Pay will be adjusted due to crop and/or weather conditions.)

6. Frequency of Pay: _________________________

7. Type of Work: Crops: _______________________________ Job activities/duties: ________________________________________

8. Transportation provided: Yes: _____ No: _______

Transportation charge (if any): $__________

9. Housing provided: Yes: _____ No: _______

Housing charge (if any): $__________

10. Any other benefits provided (such as health insurance) and related charges: __________________________

Any other charge(s)/deduction(s) to workers (must be very specific): __________________________

11. Workers’ compensation insurance provided: Yes: ____ No: ____

Name of compensation carrier: ____________________________

Name and address of policyholder(s): _________________________________________________________________________________

Person(s) and phone number(s) of person(s) to be notified to file claim:

Deadline for filing claim:

12. Unemployment compensation insurance provided: Yes: No:

13. List any strike, work stoppage, slowdown, or interruption of operation by employees at the place where the workers will be employed. (If there are no strikes, etc., enter “None”):

13. List any arrangements that have been made with establishment owners or agents for the payment of a commission or other benefits for sales made to workers. (If there are no such arrangements, enter “None”):

Name of Person(s) Providing This Information: ______________________________________________________________________________

Note: The Department of Labor–Wage and Hour Division makes this form available in certain other languages to enable employers to satisfy the requirement that the terms and conditions of employment be disclosed in a language common to the workers. Contact the nearest office of the Wage and Hour Division to obtain such forms.

While completion of Form WH516 is optional, it is mandatory for Farm Labor Contractors, Agricultural Employers, and Agricultural Associations to disclose employment terms and conditions in writing to migrant and day-haul workers upon recruitment, and to seasonal workers other than day-haul workers upon request when an offer of employment is made to respond to the information collection contained in 29 CFR §§ 500.75-

500.76. This optional form may be used to disclose the required information. Thereafter, any migrant or seasonal worker has the right to have, upon request, a written statement provided to him or her by the employer, of the information described above. This optional form may also be used for this purpose.

We estimate that it will take an average of 28 minutes to complete this collection of information, including the time to review instructions, search existing data sources, gather and maintain the data needed, and complete and review the collection of information. If you have any comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, send them to the Administrator, Wage and Hour Division, Room S3502, 200 Constitution Avenue NW, Washington, D.C. 20210. Do NOT send the completed form to this office.

REV 01/23

Persons are not required to respond to this information unless it displays a currently valid OMB number. ^{Optional form WH516 ENG}