LABOR COMMISSIONER, STATE OF CALIFORNIA BUREAU OF FIELD ENFORCEMENT STATE OF CALIFORNIA-DEPARTMENT OF INDUSTRIAL RELATIONS DIVISION OF LABOR STANDARDS ENFORCEMENT OFFICE USE ONLY TAKEN BY: _________ DATE FILED: __________________ INDUSTRY:__________________ Please print legibly or type. Fill out this form if you would like to report a widespread violation of workplace laws (e.g., wage and hour, child labor, workers' compensation, or recordkeeping laws) by an employer that affects all or a group of employees working for the employer. If you are claiming only unpaid wages on behalf of yourself and do not wish to report a widespread violation of the law by your employer that also affects other workers, then fill out the DLSE Form 1 (Initial Report or Claim) to file an individual wage claim, instead of this form. REPORT OF LABOR LAW VIOLATION SECTION 1. REPORTING PARTY (INDIVIDUAL OR REPRESENTATIVE) NAME OF REPORTING PARTY: ___________________________________ IF INTERPRETER IS NEEDED, INDICATE LANGUAGE:___________________ ADDRESS: _______________________________________________________ CITY:___________________ STATE:________ ZIP:______________ HOME PHONE: (_____)_______________ CELL/OTHER PHONE: (_____)________________ E-MAIL (if available): ___________________________ If you are represented by a lawyer or other advocate, enter your ADVOCATE and ORGANIZATION information: NAME: ___________________________________ ORGANIZATION NAME:___________________________________________________________ ADDRESS: _______________________________________________ CITY:___________________________ STATE:________ ZIP:______________ HOME PHONE: (_____)_______________ CELL/OTHER PHONE: (______)_______________ E-MAIL (if available): ___________________________ SECTION 2. EMPLOYER REPORTED EMPLOYER BUSINESS NAME: ________________________________________________________________________________________________ ADDRESS: ________________________________________________________ CITY: ________________ STATE:______ ZIP: __________________ PHONE: (____)_________________ TYPE OF BUSINESS: _____________________________________________ TOTAL EMPLOYEES: ___________ ENTITY TYPE: CORPORATION INDIVIDUAL PARTNERSHIP LLC LLP OTHER (explain): ____________________ OWNER'S NAME: _______________________ NAME AND JOB TITLE OF PERSON IN CHARGE: ____________________________________________ ADDRESS CITY, STATE, ZIP EMPLOYER'S MAIN WORK LOCATION OTHER WORK LOCATION (if any, whether or not you worked there) OTHER WORK LOCATION (if any, whether or not you worked there) EMPLOYER STILL OPERATING THERE? BUSINESS HOURS TOTAL EMPLOYEES YES NO UNKNOWN YES NO UNKNOWN YES NO UNKNOWN IS THE EMPLOYER COVERED BY WORKERS' COMPENSATION INSURANCE? YES NO UNKNOWN IS THERE A UNION CONTRACT? YES NO DID YOUR JOB INVOLVE PUBLIC WORKS? YES NO EMPLOYER'S VEHICLE LICENSE PLATE NUMBER: _____________________________________ SECTION 3. WORK HOURS AND WAGES DO YOU OR DID YOU WORK FOR THE EMPLOYER? YES NO IF "YES": DATE OF HIRE: ______ / _____ /______ LAST DAY OF WORK (if applicable): _____/______/______ QUIT DID THE EMPLOYER DESIGNATE WHAT TIME THE WORKDAY BEGAN FOR EMPLOYEES? YES WHAT TIME DID THE EMPLOYER DESIGNATE? _______ AM PM NO FIRED STILL EMPLOYED IF "YES": DON'T KNOW DID THE EMPLOYER DESIGNATE WHICH DAY OF THE WEEK THE WORKWEEK BEGAN? YES NO DON'T KNOW IF "YES": WHAT DAY DID THE EMPLOYER DESIGNATE? SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY WHAT IS THE NORMAL OR STANDARD WORK SCHEDULE FOR EMPLOYEES DURING THE WEEK? PROVIDE YOUR BEST ESTIMATE OF THE START AND END TIMES AND NUMBER OF HOURS WORKED FOR EACH WORK DAY. (If employees did not work standard schedules, skip to the next question.) SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY BOFE 1 (Rev. 11/2012) START TIME: START TIME: START TIME: START TIME: START TIME: START TIME: START TIME: ________ AM ________ AM ________ AM ________ AM ________ AM ________ AM ________ AM PM PM PM PM PM PM PM END TIME: END TIME: END TIME: END TIME: END TIME: END TIME: END TIME: _______ AM _______ AM _______ AM _______ AM _______ AM _______ AM _______ AM PM PM PM PM PM PM PM HOURS WORKED: ________ HOURS WORKED: ________ HOURS WORKED: ________ HOURS WORKED: ________ HOURS WORKED: ________ HOURS WORKED: ________ HOURS WORKED: ________ TOTAL HOURS WORKED PER WEEK: ________ Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com SECTION 3. WORK HOURS AND WAGES (continued) DO EMPLOYEES WORK DIFFERENT SCHEDULES OR IRREGULAR HOURS SO YOU CANNOT PROVIDE A STANDARD WORK SCHEDULE? YES NO IF "YES," BRIEFLY DESCRIBE THE DIFFERENT SCHEDULES OR IRREGULAR WORK HOURS AS BEST AS YOU CAN: ____________________________ ____________________________________________________________________________________________________________________ WHEN IS THE NORMAL OR STANDARD SCHEDULED MEAL PERIOD FOR EMPLOYEES? START TIME: _________ AM PM END TIME: _________ AM PM THERE IS NO STANDARD SCHEDULED MEAL PERIOD HOURS WHAT IS THE AVERAGE LENGTH OF TIME FOR AN EMPLOYEE'S MEAL PERIOD? ________ MINUTES WHO SET THE WORK SCHEDULE? (FULL NAME AND JOB TITLE/POSITION): ____________________________________________________________ WHAT DAY IS PAY DAY? DAILY WEEKLY ON __________________________ MONTHLY ON ________________________ BI-WEEKLY ON (Once every two weeks) __________________________ SEMI-MONTHLY ON (Twice a month) ____________________________ WHO PAYS EMPLOYEES? (FULL NAME AND JOB TITLE/POSITION): ___________________________________________________________________ ARE EMPLOYEES PAID BY THE HOUR? YES NO IF "YES," HOW MUCH? $ __________ PER HOUR VARIES (EXPLAIN):_____________________________________________________________________________________________________ ARE EMPLOYEES PAID A FIXED AMOUNT OF WAGES (OR SALARY), REGARDLESS OF THE NUMBER OF HOURS WORKED? YES NO IF "YES," HOW MUCH? $ ___________ PER DAY PER WEEK EVERY 2 WEEKS SEMI-MONTHLY MONTHLY VARIES (EXPLAIN):_____________________________________________________________________________________________________ ARE EMPLOYEES PAID BY PIECE RATE? YES NO IF "YES," HOW MUCH? $ ________ PER (Describe Unit) ___________________________ PIECE RATES VARY (EXPLAIN): ____________________________________________________________________________________________ HOW ARE EMPLOYEES PAID? CHECK CASH BOTH CHECK & CASH OTHER METHOD (EXPLAIN): ________________________________________________ METHOD OF PAYMENT VARIES PER EMPLOYEE OR JOB POSITION (EXPLAIN): _______________________________ ______________