Optional Form Wh-516 - Migrant And Seasonal Agricultural Worker Protection Act

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U.S. Department of Labor

Migrant and Seasonal Agricultural

Worker Protection Act

Employment Standards Administration

Wage and Hour Division

OMB No.: 1215-0187

Persons are not required to respond to this information unless it displays a currently valid OMB number.

/31/

Expires: 05

2011

Worker Information — Terms and Conditions of Employment

1. Place of employment:

_______________________________________________________________________________________________

2. Period of employment:

From _______________________

_____________________________

3. Wage rates to be paid:

__________________ per Hour

Piece Rate $

__________________

per

_____________________

Crops and kinds of activities:

__________________________________________________________________________________________

5. Transportation or other benefits, if any: __________________________________________________________________________________

_________________________________________________________________________________________________________________

Charge(s) to workers, if any:

__________________________________________________________________________________________

6. Workers’ compensation insurance provided:

Yes

__________________

Name of compensation carrier:

________________________________________________________________________________________

Name and address of policyholder(s)

___________________________________________________________________________________

_________________________________________________________________________________________________________________

Person(s) and phone number(s) of person(s) to be notified to file claim:

________________________________________________________

_________________________________________________________________________________________________________________

Deadline for filing claim:

______________________________________________________________________________________________

7. Unemployment compensation insurance provided:

Yes

__________________

8. Other benefits: ____________________________________________________________________________

Charge(s)

_______________

9. For migrant workers who will be housed, the kind of housing available and cost, if any:

____________________________________________

_________________________________________________________________________________________________________________

Charge(s)

_________________________________________________________________________________________________________

10. List any strike, work stoppage, slowdown, or interruption of operation by employees at the place where the workers will be employed.

(If there

are no strikes, etc., enter “None”)

_________________________________________________________________________________________________________________

11. List any arrangements which have been made with establishment owners or agents for the payment of a commission or other benefits for

sales made to workers. (If there are no such arrangements, enter “None”)

_________________________________________________________________________________________________________________

Name of Person(s) Providing This Information:

_____________________________________________________________________________

Note:

The Department of Labor — Wage and Hour Division makes this form available in certain other languages to enable employers to satisfy the

requirement that the terms and conditions of employment be disclosed in a language common to the workers. Contact the nearest office of the Wage

and Hour Division to obtain such forms.

The Migrant and Seasonal Agricultural Worker Protection Act requires the disclosure in writing of the foregoing information to migrant and day-haul

workers upon recruitment, and to seasonal workers other than day-haul workers upon request when an offer of employment is made.

This optional

form may be used to disclose the required information. Thereafter, any migrant or seasonal worker has the right to have, upon request, a written

statement provided to him or her by the employer, of the information described above. This optional form may also be used for this purpose.

We estimate that it will take an average of 32 minutes to complete this collection of information, including the time for reviewing instructions, search

existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have any

comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, send

them to the Administrator, Wage and Hour Division, Room S-3502, 200 Constitution Avenue, N.W., Washington, D.C.

20210.

Do NOT Send the

Completed Form to This Office

Optional Form WH-516 English

Rev. May 1996