Report Of Labor Law Violation Form (Bofe 1)

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CLEAR

LABOR COMMISSIONER, STATE OF CALIFORNIA

BUREAU OF FIELD ENFORCEMENT

OFFICE USE ONLY

TAKEN BY: _________ DATE FILED: __________________ INDUSTRY:__________________

STATE OF CALIFORNIA-DEPARTMENT OF INDUSTRIAL RELATIONS

DIVISION OF LABOR STANDARDS ENFORCEMENT

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

EMPLOYER STILL

BUSINESS

TOTAL

CITY, STATE, ZIP

OPERATING THERE?

HOURS

EMPLOYEES

 YES

 NO

EMPLOYER’S MAIN WORK LOCATION

 UNKNOWN

 YES

 NO

OTHER WORK LOCATION

 UNKNOWN

(if any, whether or not you worked there)

 YES

 NO

OTHER WORK LOCATION

 UNKNOWN

(if any, whether or not you worked there)

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

 FIRED

STILL EMPLOYED

DID THE EMPLOYER DESIGNATE WHAT TIME THE WORKDAY BEGAN FOR EMPLOYEES?  YES

 NO

 DON’T KNOW

IF “YES”:

WHAT TIME DID THE EMPLOYER DESIGNATE? _______  AM  PM

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.)