Form Lb001ff - Fast Food Worker Complaint Form
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2OFFICE OF ATTORNEY GENERAL ERIC T. SCHNEIDERMAN
STATE OF NEW YORK DEPARTMENT OF LAW
FAST FOOD WORKER COMPLAINT FORM
th
Labor Bureau, 120 Broadway, 26
Fl, NY, NY 10271 • Tel. (212) 416-8700 • Fax (212) 416-8694
EMPLOYEE
Your Name
Daytime Phone Number
Home Phone Number
Street Address
What is the best time to reach you by phone?
City/Town
State
Zip Code
Email Address
YOUR EMPLOYER(S)
Telephone Number
Name Of Your Employer
Name of owner(s)
Address (If multiple stores, list all locations.)
Name of your supervisor(s)
YOUR JOB
What is your job?
What is your usual rate of pay? $________ per hour
Dates of employment: _______________________
What is your usual work schedule? (If you work in more than one location owned by the same employer, please include your total hours at all stores).
MON. start ________ TUES. start ________ WED. start ________ THUR. start ________ FRI. start________ SAT. start ________ SUN. start ________
end ________
end ________
end ________
end ________
end ________
end ________
end ________
If you work over 40 hours in a week, what are you paid for hours worked past 40? $________ per hour
Do you usually get uninterrupted time to eat a meal during your shift? Y___ N___ How much time? ____ minutes
Do you ever have to work "off the clock" - in other words, do you have to work before clocking in or after clocking out? Y___ N___
Please use the following page to describe what happens and how often.
Are you ever told to clock out -- or wait to clock in -- because the store is not busy enough? Y___ N___
Please use the following page to describe what happens and how often.
Have you ever had a paycheck bounce? Y___ N___
How frequently? _____________________
How are you paid your wages? (Check all that apply): cash check direct deposit
paycard other
How often are you paid? weekly every two weeks other
Does your employer deduct money from your paycheck for meals that you do not eat? Y___ N___ Don't know_____
Do you have to pay your own money out of pocket for any of the following work-related expenses? Y___ N___
If yes, please check all that apply.
Buying uniform Cleaning uniform Theft Cash register shortages Delivery-related expenses (gas, repairs, car/bicycle expenses).
Please describe on the following page what your expenses were, and whether your employer reimbursed you, or paid you back.
Were you ever injured on the job? Y___ N___
If yes, did you receive workers' compensation? Y___ N___
If you receive tips: What percent of your work time do you spend doing tipped work such as delivering food?
_____ %
What percent of your work time do you spend doing non-tipped work (in kitchen, cleaning, etc.)? _____ %
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Parent category: Legal