Migrant and Seasonal Agricultural
Worker Protection Act
U.S. Department of Labor
Wage and Hour Division
OMB NO: 1235-0002
Expires: 08/31/2020
Worker Information—Terms and Conditions of Employment
1. Place of employment: ________________________________________________________________________________________________
2. Period of employment: From _______________________ To ___________________________
3. Wage rates to be paid: $ __________________ per Hour Piece Rate $____________________ per _______________________
4. Crops and kinds of activities: __________________________________________________________________________________________
5. Transportation or other benets, if any: __________________________________________________________________________________
________________________________________________________________________________________________________________
Charge(s) to workers, if any: __________________________________________________________________________________________
6. Workers’ compensation insurance provided: Yes ________ No _________
Name of compensation carrier: ________________________________________________________________________________________
Name and address of policyholder(s): ___________________________________________________________________________________
________________________________________________________________________________________________________________
Person(s) and phone number(s) of person(s) to be notied to le claim: _________________________________________________________
________________________________________________________________________________________________________________
Deadline for ling claim: ______________________________________________________________________________________________
7. Unemployment compensation insurance provided: Yes _________ No ___________
8. Other benets: __________________________________________________________________________ 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 that have been made with establishment owners or agents for the payment of a commission or other benets 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.
While completion of Form WH516 is optional, it is mandatory for Farm Labor Contractors, Agricultural Employers, and Agricultural Associations
to disclose employment terms and conditions in writing 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 to respond to the information collection contained In 29 CFR §§ 500.75-
500.76. 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 to review instructions, search
existing data sources, gather and maintain the data needed, and complete and review 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 S3502, 200 Constitution Avenue NW, Washington, D.C. 20210. Do NOT send the completed form
to this office.
Persons are not required to respond to this information unless it displays a currently valid OMB number.
Optional form WH516 ENG
REV 06/14
