Fillable REPORT OF LABOR LAW V IOLATION (California)

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REPORT OF LABOR LAW V IOLATION (California)

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BOFE 1 (Rev. 9/2020) Page 1 of 3
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LABOR COMMISSIONER, STATE OF CALIFORNIA
DEPARTMENT OF INDUSTRIAL RELATIONS - DIVISION OF LABOR STANDARDS ENFORCEMENT
BUREAU OF FIELD ENFORCEMENT
IS THIS REPORT RELATED TO COVID-19? NO YES
RELATED TO PAID SICK LEAVE (PSL/SPSL)? NO YES
OFFICE USE ONLY
TAKEN BY: DATE FILED: INDUSTRY:
Please print legibly or type. Fill out this form if you would like to report a widespread violation of workplace laws (e.g., wage and hour, child
labor, workers’ compensation, or recordkeeping laws) by an employer that affects all or a group of employees working for the employer. If
you are claiming only unpaid wages on behalf of yourself and do not wish to report a widespread violation of the law by your employer that
also affects other workers, then fill out the DLSE Form 1 (Initial Report or Claim) to file an individual wage claim, instead of this form.
REPORT OF LABOR LAW V IOLATION
SECTION 1. REPORTING PARTY (INDIVIDUAL OR REPRESENTATIVE)
NAME OF REPORTING PARTY: IF INTERPRETER IS NEEDED, INDICATE LANGUAGE:
ADDRESS: CITY: STATE: ZIP:_
HOME PHONE: CELL/OTHER PHONE: E-MAIL (if available):
If you are represented by a lawyer or other advocate, enter your ADVOCATE and ORGANIZATION information:
NAME: ORGANIZATION NAME:
ADDRESS: CITY: STATE: ZIP:_
HOME PHONE: CELL/OTHER PHONE: E-MAIL (if available):
SECTION 2. EMPLOYER REPORTED
EMPLOYER BUSINESS NAME:
ADDRESS: CITY: STATE: ZIP:
PHONE: TYPE OF BUSINESS: TOTAL EMPLOYEES:
ENTITY TYPE: CORPORATION INDIVIDUAL PARTNERSHIP LLC LLP OTHER (explain):
OWNER’S NAME: NAME AND JOB TITLE OF PERSON IN CHARGE:
ADDRESS
CITY, STATE, ZIP
EMPLOYER STILL
OPERATING THERE?
BUSINESS
HOURS
TOTAL
EMPLOYEES
EMPLOYER’S MAIN WORK LOCATION
YES NO
UNKNOWN
OTHER WORK LOCATION
(if any, whether or not you worked there)
YES NO
UNKNOWN
OTHER WORK LOCATION
(if any, whether or not you worked there)
YES NO
UNKNOWN
IS THE EMPLOYER COVERED BY WORKERS’ COMPENSATION INSURANCE? YES NO UNKNOWN
IS THERE A UNION CONTRACT? YES NO DID YOUR JOB INVOLVE PUBLIC WORKS? YES NO
EMPLOYER’S VEHICLE LICENSE PLATE NUMBER:
SECTION 3. WORK HOURS AND WAGES
DO YOU OR DID YOU WORK FOR THE EMPLOYER? YES NO IF “YES”:
DATE OF HIRE: LAST DAY OF WORK (if applicable): QUIT FIRED STILL EMPLOYED
DID THE EMPLOYER DESIGNATE WHAT TIME THE WORKDAY BEGAN FOR EMPLOYEES? YES NO DON’T KNOW IF “YES”:
WHAT TIME DID THE EMPLOYER DESIGNATE? AM PM
DID THE EMPLOYER DESIGNATE WHICH DAY OF THE WEEK THE WORKWEEK BEGAN? YES NO DON’T KNOW IF “YES”:
WHAT DAY DID THE EMPLOYER DESIGNATE? SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY
WHAT IS THE NORMAL OR STANDARD WORK SCHEDULE FOR EMPLOYEES DURING THE WEEK? PROVIDE YOUR BEST ESTIMATE OF THE START AND
END TIMES AND NUMBER OF HOURS WORKED FOR EACH WORK DAY. (If employees did not work standard schedules, skip to the next question.)
SUNDAY START TIME: AM PM END TIME: AM PM HOURS WORKED:
MONDAY START TIME: AM PM END TIME: AM PM HOURS WORKED:
TUESDAY START TIME: AM PM END TIME: AM PM HOURS WORKED:
WEDNESDAY START TIME: AM PM END TIME: AM PM HOURS WORKED:
THURSDAY START TIME: AM PM END TIME: AM PM HOURS WORKED:
FRIDAY START TIME: AM PM END TIME: AM PM HOURS WORKED:
SATURDAY START TIME: AM PM END TIME: AM PM HOURS WORKED:
TOTAL HOURS
WORKED PER
WEEK:
CLEAR
PRINT
BOFE 1 (Rev. 9/2020) Page 2 of 3
SECTION 3. WORK HOURS AND WAGES (continued)
DO EMPLOYEES WORK DIFFERENT SCHEDULES OR IRREGULAR HOURS SO YOU CANNOT PROVIDE A STANDARD WORK SCHEDULE? YES NO
____________________________
____________________________________________________________________________________________________________________
IF “YES,” BRIEFLY DESCRIBE THE DIFFERENT SCHEDULES OR IRREGULAR WORK HOURS AS BEST AS YOU CAN:
WHEN IS THE NORMAL OR STANDARD SCHEDULED MEAL PERIOD FOR EMPLOYEES?
_________
_________
START TIME: AM PM END TIME: AM PM THERE IS NO STANDARD SCHEDULED MEAL PERIOD
________
WHAT IS THE AVERAGE LENGTH OF TIME FOR AN EMPLOYEE’S MEAL PERIOD? MINUTES HOURS
____________________________________________________________ WHO SET THE WORK SCHEDULE? (FULL NAME AND JOB TITLE/POSITION):
WHAT DAY IS PAY DAY? DAILY
__________________________
__________________________ WEEKLY ON BI-WEEKLY ON (Once every two weeks)
________________________
____________________________ MONTHLY ON SEMI-MONTHLY ON (Twice a month)
___________________________________________________________________ WHO PAYS EMPLOYEES? (FULL NAME AND JOB TITLE/POSITION):
__________ ARE EMPLOYEES PAID BY THE HOUR? YES NO IF “YES,” HOW MUCH? $ PER HOUR
_____________________________________________________________________________________________________
VARIES (EXPLAIN):
ARE EMPLOYEES PAID A FIXED AMOUNT OF WAGES (OR SALARY), REGARDLESS OF THE NUMBER OF HOURS WORKED? YES NO
___________
IF “YES,” HOW MUCH? $ PER DAY PER WEEK EVERY 2 WEEKS SEMI-MONTHLY MONTHLY
_____________________________________________________________________________________________________
VARIES (EXPLAIN):
________ ___________________________ ARE EMPLOYEES PAID BY PIECE RATE? YES NO IF “YES,” HOW MUCH? $ PER (Describe Unit)
____________________________________________________________________________________________
PIECE RATES VARY (EXPLAIN):
HOW ARE EMPLOYEES PAID? CHECK CASH
________________________________________________ BOTH CHECK & CASH OTHER METHOD (EXPLAIN):
_______________________________ METHOD OF PAYMENT VARIES PER EMPLOYEE OR JOB POSITION (EXPLAIN):
______________________________________________________________________________________________
IF EMPLOYEES ARE PAID IN CASH, DOES THE EMPLOYER KEEP CASH PAYMENT RECORDS OR LOGS? YES NO DON’T KNOW
DOES THE EMPLOYER KEEP TIME RECORDS OF HOURS WORKED BY EMPLOYEES? YES NO DON’T KNOW
WHAT LANGUAGES ARE SPOKEN BY EMPLOYEES? ENGLISH SPANISH MIXTEC TRIQUE CANTONESE MANDARIN KOREAN
_____________ VIETNAMESE TAGALOG CAMBODIAN HMONG THAI PUNJABI HINDI RUSSIAN OTHER:
SECTION 4. SUSPECTED VIOLATIONS OF EMPLOYER
The boxes below describe conduct by an employer that violates the law. Please put a check mark in the box(es) if the employer
engages in, or any employee or employees have experienced, any of the following violations:
NO WORKERS’ COMPENSATION INSURANCE
CHILD LABOR VIOLATIONS:
No valid work permit(s)
No valid entertainment work permit(s)
Minor(s) work excessive or prohibited hours
Minor(s) work in hazardous conditions
_________ Estimated number of minors affected:
MINIMUM WAGE VIOLATIONS:
Paid below minimum wage
Not paid at all for overtime hours worked
Not paid for all hours worked, including unpaid travel time and
try-out time
Paycheck issued with insufficient funds
Asked employee to pay back wages paid
No split shift premium pay
_________ Estimated number of employees affected:
OVERTIME VIOLATIONS:
Not paid daily overtime for hours worked over 8 hours per
day (or 10 hours per day for farmworkers)
Not paid weekly overtime for hours worked over 40 hours
per week
Not paid double time for hours worked over 12 hours per
day
Not paid overtime for working on the 7th consecutive
workday in a workweek
_________
Estimated number of employees affected:
BOFE 1 (Rev. 9/2020) Page 3 of 3
SECTION 4. SUSPECTED VIOLATIONS OF EMPLOYER (continued)
OTHER UNPAID WAGES:
Wages are not paid at the contracted rate
No reporting time premium pay
No premium pay for missing meal or rest periods
_________ Estimated number of employees affected:
PAY STUB VIOLATIONS:
Paid by check or cash without an itemized wage deduction
statement
Itemized wage deduction statement provided but not
accurate and/or incomplete
Itemized wage deduction statement not provided at least
semi-monthly
_________ Estimated number of employees affected:
MEAL PERIOD VIOLATIONS:
30-minute off-duty meal period not provided by the end of the
5th hour of work
Second 30-minute off-duty meal period not provided when
working more than 10 hours
Meal period provided but less than 30 minutes
_________ Estimated number of employees affected:
REST BREAK VIOLATIONS:
For work days between 3.5 hours and up to 6 hours per day,
not allowed to take a 10-minute rest break
For work days of more than 6 hours and up to 10 hours per
day, not allowed to take two 10-minute rest breaks
For work days of more than 10 hours and up to 14 hours
per day, not allowed to take three 10-minute rest breaks
_________ Estimated number of employees affected:
PAY DATE VIOLATIONS:
No fixed pay date
Late payment of wages
_________ Estimated number of employees affected:
RECORD KEEPING VIOLATIONS:
Daily time records are not kept or inaccurate
Payroll records are not kept or inaccurate
No notice to new hires (under Labor Code Section 2810.5)
BUSINESS EXPENSE VIOLATIONS:
Uniforms not reimbursed or illegally charged to employees
Tools, supplies or equipment not reimbursed or illegally charged
to employees
Illegal charges for cash shortages, breakage, or loss of
equipment
_________ Estimated number of employees affected:
FAILURE TO POST:
Applicable Industrial Welfare Commission Order not posted
Minimum Wage Order 2001 not posted
Pay day notice not posted
Workers’ compensation insurance notice not posted
Rate of compensation not posted (for farmworkers only)
MISCLASSIFICATION:
Employees misclassified as independent contractors
Salaried employees misclassified as exempt employees
_________ Estimated number of employees affected:
LICENSING/REGISTRATION VIOLATIONS:
Unlicensed construction contractor
Contracted with unlicensed construction contractor
Unlicensed farm labor contractor
Unregistered garment contractor or manufacturer
Unregistered car wash
FAILURE TO PROVIDE LACTATION ACCOMMODATIONS
_________ Estimated number of employees affected:
OTHER VIOLATIONS (briefly explain):
_________________________________
__________
_________
Estimated number of employees affected:
Please provide any other information about your complaint that you believe is important for the Labor Commissioner to know:
Please provide the following information for any minors under the age of 18 who work for the employer:
FULL NAME
(first and last name, and
any “nick” names)
AGE JOB POSITION/ TYPE OF
WORK PERFORMED
NORMAL WORK SCHEDULE HOW WAS THE MINOR PAID
(by check, in cash, both cash and
check, or other method)?
MAY YOUR NAME BE USED IN AN INVESTIGATION? YES NO
DO YOU WANT DLSE TO KEEP YOUR NAME AND CONTACT INFORMATION CONFIDENTIAL? *
YES NO
I HEREBY CERTIFY THAT THE INFORMATION ABOVE IS A TRUE STAT
EMENT TO THE BEST OF MY KNOWLEDGE.
SIGNED: ______________________________________________ ________________________________________ DATE:
__________________________________________ PRINT NAME:
* DLSE will maintain confidentiality as appropriate in each case and to the extent provided for under the law. Information may need to be released in some cases.
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REPORT OF LABOR LAW V IOLATION (California)

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Completed 27 April 2021

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