Employee'S Confidential Complaint Statement Form - Department Of Labor Wage And Hour Division

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DEPARTMENT OF LABOR
Roman L.G. Quinata, Jr.,
WAGE AND HOUR DIVISION
Administrator
James H. Underwood
Director, Acting
Kenneth M.R. Cruz
Deputy Director
EMPLOYEE’S CONFIDENTIAL COMPLAINT STATEMENT
EMPLOYER’S INFORMATION
Name of Employer:________________________________________________________
Name of Owner/Supervisor:________________________________________________
Contact Nos.
:______________________________________
(Home/Work/Fax/Cell/Pager)
Home Address
______________________________________
(Draw map on reverse side):
_____________________________________
Office Address
(Draw map on reverse side):
Mailing Address:____________________________________________________________
Nature of Business:_________________________________________________________
COMPLAINANT’S INFORMATION
Name
:________________________________ Social Security No.:___________
(PRINT)
Contact Nos.
:______________________________________
(Home/Work/Fax/Cell/Pager)
Home Address:______________________________________________________________
Mailing Address:____________________________________________________________
FOR STATISTICAL PURPOSES ONLY:
ETHNICITY
/ / Caucasian
/ / Chamorro
/ / Chinese
/ / Filipino
/ / African American
/ / Korean
/ / Japanese
/ /Asian Pacific Islander
/ / Chuukese
/ / Yapese
/ / Palauan
/ / Pohnepian
/ / Kosraean
/ / Marshallees
/ / OTHER:___________________ (specify)
FOR STATISTICAL PURPOSES:
CITIZENSHIP / / U.S. / /PRA
/ / Resident
/ / Other (Specify): _____________________
Employment Status: / /Local Hire / /Contractual / /Non-Immigrant
Current Status:
/ /Still employed / /Resigned / /Terminated/Fired
If terminated/fired/resigned, indicate last day of work:___________________
Position Title/Occupation:__________________________________________________
How many minutes is your meal/lunch period? ____________________
minutes
How are you paid/compensated:
/ /Hourly @ $________ / /Salary @ $_________
/ /Semi-Monthly @ $________ / /Bi-Weekly @ $________ / /Monthly @ $____________
_________________________________
/ /Commission @ $_________ / /Other
(Specify):
Date of Employment
(FROM)_____________________________ (TO)__________________________
Employee’s Confidential Complaint Statement
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