Form Dlse-Pw 1 - Public Works - Worker Complaint Form - California Department Of Industrial Relations

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Labor Commissioner, State of California
DIVISION USE ONLY:
Department of Industrial Relations
TAKEN BY:
CASE #
Division of Labor Standards Enforcement
DATE TAKEN:
ASSIGNED TO:
OFFICE:
DATE RECEIVED:
DATE ASSIGNED:
PUBLIC WORKS – WORKER COMPLAINT
The following information is important and must be provided.
Complainant/Worker Information
1. FIRST NAME
2. LAST NAME
3. HOME TEL. NO.
4. WORK/CELLULAR NO
5. CONTACT ADDRESS
6. CITY
7. STATE/ ZIP CODE
8. EMAIL ADDRESS
Project Information
Note: A separate form must be completed for each project in which you are alleging a violation of prevailing wages.
9. PROJECT NAME (If known)
10. LIST THE ADDRESSES OF THE PROJECT WHERE YOU PERFORMED WORK:
Complaint Against
12. CONTRACTOR’S STATE LIC.
11. NAME OF BUSINESS/CONTRACTOR/EMPLOYER
NO
14. BUSINESS TEL. NO
13. ADDRESS
15. NAME OF PERSON IN CHARGE/ TITLE
16. EMAIL ADDRES
17. ARE YOU STILL WORKING FOR THIS CONTRACTOR?
Awarding Body
18. NAME OF PUBLIC AGENCY/AWARDED CONTRACT ENTITY
19. ADDRESS
20. BUSINESS TEL. NO
21. NAME OF PERSON IN CHARGE/ TITLE
22. EMAIL ADDRESS
23. DATE PROJECT BEGAN
24. ESTIMATED COMPLETION DATE
25. DATE OF NOTICE OF COMPLETION
General Contractor (Prime Contractor)
27. CONTRACTOR’S STATE LIC.
26. NAME OF GENERAL CONTRACTOR
28. ADDRESS
29. BUSINESS TEL. NO
30. NAME OF PERSON IN CHARGE/ TITLE
31. EMAIL ADDRESS
Issues
32. BRIEF EXPLAINATION OF ISSUES: (Check all applicable boxes)
Non-payment /Underpayment of wages
Not paid travel and subsistence
Under reporting of hours
Insufficient fund check
Unpaid overtime/Sat/Sun/Holiday rate
Misclassification of worker
Fringe benefits not paid
Other
DLSE-PW 1 (Revised Sept/2012)
(Continued on next page)

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