Form Dlse-Pw 1 - Public Works - Worker Complaint Form - California Department Of Industrial Relations Page 2

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Employment Information
33. WHAT WAS YOUR JOB TITLE?
34. DESCRIBE YOUR JOB DUTIES?
35. WHAT TOOLS DID YOU USE TO PERFORM YOUR JOB DUTIES?
36. HOW WERE YOU PAID?
Check
Cash
Direct Deposit
Other
37. WERE YOU GIVEN A CHECK STUB?
Yes
No
38. HOW OFTEN WERE YOU PAID?
Daily
Weekly
Bi-weekly
Monthly
Semi-Monthly
Other
39. HOW MUCH WERE YOU PAID? $ ______________________
Per Hour
Per Day
Per Week
40. WERE YOU PAID: (Please check all applicable boxes)
No ___ Yes ___ $ _______ ________
No ___ Yes ___ $_______ ___________
Overtime Rate
Saturday Rate
Double Time Rate No ___ Yes ___ $________ _______
Sun/Holiday Rate No ___ Yes ___ $________ _________
41. DID YOUR EMPLOYER KEEP TIME AND PAYROLL
No
RECORDS?
Yes
Do Not Know
42. WHO WAS IN POSSESSION OF THESE RECORDS?
43. DID YOU KEEP AN ACCURATE RECORD OF YOUR HOURS WORKED?
Yes
No
44. DATES YOU WORKED ON THIS PROJECT:
45. DID YOU WORK ON ANOTHER PROJECT AT THE SAME TIME YOU WORKED ON THIS PROJECT?
Yes
No
46. IF YES, FOR WHO?
WHERE?
WHEN?
HOURS
47. DID YOU RECEIVE TRAVEL AND SUBSISTENCE PAYMENT?
NO
YES, IF YES, HOW MUCH? $___________________
48. LIST CO-WORKERS/WITNESS INFORMATION:
Estimated number of workers who you are working with in this project: ___________________________________________________________
Please provide names, addresses, telephone numbers, and type of work of other workers? Please list their names below. Use additional sheets as
necessary.
Name of Worker
Address
Telephone No.
Types of Work Performed
1)
2)
3)
I hereby certify that this is a true statement to the best of my knowledge and belief.
MY NAME MAY BE USED IN THIS INVESTIGATION.
Yes
No
____________________________________
____________________________________
Signature
Date
DLSE-PW 1 (Revised Sept/2012)

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