Report Of Labor Law Violation Form (Bofe 1) Page 3

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SECTION 4. SUSPECTED VIOLATIONS OF EMPLOYER (continued)

 OTHER UNPAID WAGES:

 PAY STUB VIOLATIONS:

 Wages are not paid at the contracted rate

 Paid by check or cash without an itemized wage deduction

 No reporting time premium pay

statement

 No premium pay for missing meal or rest periods

 Itemized wage deduction statement provided but not

accurate and/or incomplete

 Itemized wage deduction statement not provided at least

Estimated number of employees affected: _________

semi-monthly

Estimated number of employees affected: _________

 MEAL PERIOD VIOLATIONS:

 REST BREAK VIOLATIONS:

 30-minute off-duty meal period not provided by the end of the

 For work days between 3.5 hours and up to 6 hours per day,

5th hour of work

not allowed to take a 10-minute rest break

 Second 30-minute off-duty meal period not provided when

 For work days of more than 6 hours and up to 10 hours per

working more than 10 hours

day, not allowed to take two 10-minute rest breaks

 Meal period provided but less than 30 minutes

 For work days of more than 10 hours and up to 14 hours

per day, not allowed to take three 10-minute rest breaks

Estimated number of employees affected: _________

 PAY DATE VIOLATIONS:

 RECORD KEEPING VIOLATIONS:

 No fixed pay date

 Daily time records are not kept or inaccurate

 Late payment of wages

 Payroll records are not kept or inaccurate

 No notice to new hires (under Labor Code Section 2810.5)

Estimated number of employees affected: _________

 BUSINESS EXPENSE VIOLATIONS:

 FAILURE TO POST:

 Uniforms not reimbursed or illegally charged to employees

 Applicable Industrial Welfare Commission Order not posted

 Tools, supplies or equipment not reimbursed or illegally charged

 Minimum Wage Order 2001 not posted

to employees

 Pay day notice not posted

 Illegal charges for cash shortages, breakage, or loss of

 Workers’ compensation insurance notice not posted

 Rate of compensation not posted (for farmworkers only)

equipment

Estimated number of employees affected: _________

 MISCLASSIFICATION:

 LICENSING/REGISTRATION VIOLATIONS:

 Employees misclassified as independent contractors

 Unlicensed construction contractor

 Salaried employees misclassified as exempt employees

 Contracted with unlicensed construction contractor

 Unlicensed farm labor contractor

 Unregistered garment contractor or manufacturer

Estimated number of employees affected: _________

 Unregistered car wash

 FAILURE TO PROVIDE LACTATION ACCOMMODATIONS

 OTHER VIOLATIONS

(briefly explain):

___________________________________________

Estimated number of employees affected: _________

Please provide any other information about your complaint that you believe is important for the Labor Commissioner to know:

Please provide the following information for any minors under the age of 18 who work for the employer:

FULL NAME

AGE

JOB POSITION/ TYPE OF

NORMAL WORK SCHEDULE

HOW WAS THE MINOR PAID

(first and last name, and

WORK PERFORMED

(by check, in cash, both cash and

any “nick” names)

check, or other method)?

MAY YOUR NAME BE USED IN AN INVESTIGATION?  YES

 NO

DO YOU WANT DLSE TO KEEP YOUR NAME AND CONTACT INFORMATION CONFIDENTIAL? *  YES

 NO

I HEREBY CERTIFY THAT THE INFORMATION ABOVE IS A TRUE STATEMENT TO THE BEST OF MY KNOWLEDGE.

SIGNED: ______________________________________________

DATE: ________________________________________

PRINT NAME: __________________________________________

* DLSE will maintain confidentiality as appropriate in each case and to the extent provided for under the law. Information may need to be released in some cases.

BOFE 1 (Rev. 11/2012)

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