Complaint/Apparent Violation Form

U.S. Department Labor                                                                OMB Approval No. 1205-0039
                    Employment and Training Administration                                               Expiration Date: 03/31/2027

For Official Use Only Complaint/Apparent Violation Form 1                     0F




    Complaint/Apparent Violation No.                                               Date Received

     Part I. Contact Information 2       1F
                                                                                   Respondent’s Information 3        2F




     1. Name of Complainant/(Last, First, Middle Initial) 4    3F                  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 Complainant 5   4F                                                             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
 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.
    Part II. For Official Use Only
 1. Migrant or Seasonal Farmworker?
   0B

                                                         4. Issue(s) involved in Complaint or Apparent                 5. If employer is an H-2A/Criteria
              Yes        No                                   Violation (“X” Appropriate Box(es)):                     Employer, is the complainant a:
 2. Complaint or Apparent Violation                                                                                       (“X” Appropriate Box):
 Employment Service Related (“X”                                       Wage Related                  Housing
 Appropriate Box(es))                                                                                                           U.S. Worker
        Complaint against the Employer                                 Child Labor                    Pesticides
                                                                                                                                H-2A Worker
        Apparent violation involving the                               Health/Safety                  Discrimination
          Employer
        Complaint against the Local                                    Transportation                 Trafficking
          Employment Service Office
        Apparent violation involving the                                Sexual harassment/coercion/assault
          Employment Service Office                               [
 2a. Job Order No, if available:                                        Other (Specify)____________________
 _________________________
 3. Complaint or Apparent Violation Employment-
Related Law:
                   Yes           No



  6a. Referrals To Other Agencies (“X” Appropriate Box(es))           7. Address of Referral Agency (No., St., City, State, ZIP Code and
         WHD. U.S. DOL.         OSHA U.S. D.O.L.                         Telephone No.)
         EEOC                   Other
  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* _________________________________________

 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.