WH-3 Employment Information Form

U.S. Department of Labor

Employment Information Form

Wage and Hour Division

This report is authorized by Section 1 1 of the Fair Labor Standards Act. While you are not required to respond, submission
of this information is necessary for the Division to schedule any compliance action. Your identity will be kept confidential
to the maximum extent possible under existing law. Persons are not required to respond to this collection of information
unless it displays a currently valid OMB control number.
1. Person Submitting Information
A. Name (Print first name, middle initial, and last name)

OMB No. 1235-0021
Expires: xx-xx-xxxx

B. Date

Mr.
Miss

C. Telephone number:

Mrs.

Home:

Ms.

Work:

D. Address: (Number, Street, Apt. No.)

(City, County, State, Zip Code)

E. Check one of these boxes
Present employee
of establishment

Former employee
of establishment

Other
(Specify: relative, union, etc)

2. Establishment Information
A. Name of establishment/Name of Contact and Title

B. Telephone Number

C. Address of establishment: (Number, Street)

(City, County, State, Zip Code)

D. Estimate number of employees

E. Does the firm have branches?

Yes

No

Don't know

lf ''Yes'', name one or two locations:

F. Sector: (Select One)

Private non-profit

Private for-profit

Public agency

Nature of establishment's business: (For example; school, farm, hospital, hotel, restaurant, shoe store, wholesale drugs, manufactures stoves,
coal mine, construction, trucking, etc.)
G. lf the establishment has a Federal Government or federally assisted contract, check the appropriate box(es).
Furnishes goods

Furnishes services

Performs construction

Don't Know

H. Does establishment ship goods to or receive goods from other States?
Yes (describe)

No

Don't know

3. Employment Informatilon (Complete A, B, C, D, E, & F if present or former employee of establishment; otherwise complete F only), complete G
only if a potential violation of the Family and Medical Leave Act)
A. Period employed (month, year)
B. Date of birth if you were younger than 19, at any time
while employed at this establishment
From:
To:

Month

(lf still there, state present)

Day

Year

C. Give your job title and describe briefly the kind of work you do (or did)

(Continue on other side)

Form WH-3
Rev.March 2011

D. Frequency of payment (check appropriate box)
Weekly
Method of payment $

Semi-Monthly

Bi-Weekly
(Rate)

per

Monthly

Other

E. Enter in the boxes below the hours you usually
work (or worked) each day and each week (less
time off for meals)

M

T

W

T

F

S

S

Total

(Hour, week, month, etc.)

F. Check the appropriate box(es) and explain briefly in the space below the employment practices whichyou believe violate the Wage
and Hour laws. (If you need more space use an additional sheet of paper and attach it to this form.)
Does not pay the minimum wage
(explain below)

Excessive deduction or discharge because of wage garnishment
(explain below)

Does not pay proper overtime
(explain below)

Employs minors under minimum age for job, for excessive
hours, or in illegal occupations (explain below)

Does not pay prevailing wage/fringe benefits for
Federal Government or federally assisted contracts
(explain below)
Approximate date government contract ends

Violation of Family and Medical Leave Act (FMLA)
(complete G below)
Other (explain below)

Violation of Migrant and Seasonal Agricultural Worker
Protection ACt (explain below)
Explanation:

G. Family and Medical Leave Act (FMLA) Eligibility
(i) Number of hours employee worked during 12 months prior to the start of FLMA leave
(ii) Employee works at a location where at least 50 or more employees are employed within 75 miles

Yes

No

(iii) Leave Reason (check one)
Birth of a child

Adoption or foster care placement

Employee's serious health condition

Care for a spouse, child or parent with a serious health condition

(Note: lf you think it would be difficult for us to locate the establishment or where you live, give directions or attach map.)

Complaint Taken By:

Public Burden Statement
We estimate that it will take an average of 20 minutes to complete this collection of information, including time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden, to the U.S. Department of Labor, Administrator, Wage and Hour Division,Room S3502, 200 Constitution Avenue, N.W.,
Washington, D.C. 20210. DO NOT SEND THE COMPLETED FORM TO THIS OFFICE.