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October 23, 2017
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Worker Complaint Form

PUBLIC WORKS - PUBLIC COMPLAINT

The following information is important and must be provided.

Complainant Information

1.  FIRST NAME

2. LAST NAME

3. COMPANY NAME

4.  WORK/CELLULAR NO

5.  CONTACT ADDRESS

6. CITY

7. STATE / ZIP CODE

8. EMAIL ADDRESS

Project Information

Note: A separate form must be completed for each project in which you are alleging a violation of prevailing wages.

9.  PROJECT NAME (If known)

10. LIST ADDRESS(ES) OF PROJECT WHERE WORK WAS PERFORMED:

Complaint Against

11. NAME OF BUSINESS/CONTRACTOR/EMPLOYER

12. CONTRACTOR'S STATE LIC. NO

13. ADDRESS OF BUSINESS/CONTRACTOR/EMPLOYER (Include Zip Code)

14.  BUSINESS TEL. NO

 

15. EMAIL ADDRESS

16. NAME OF PERSON IN CHARGE

17. TITLE

   DESCRIBE IN DETAIL THE ISSUES OR SUSPECTED VIOLATION:
   

Awarding Body

18. NAME OF PUBLIC AGENCY/AWARDED CONTRACT ENTITY

19. ADDRESS OF AWARDING BODY

20. BUSINESS TEL. NO

 

21. EMAIL ADDRESS

22. NAME OF PERSON IN CHARGE / TITLE

23. AMOUNT OF CONTRACT

24. FIRST BID AD DATE

25.DATE PROJECT BEGAN

26. PROPOSED FINISH DATE

27. DATE OF NOTICE OF COMPLETION

General Contractor (Prime Contractor)

28. NAME OF GENERAL CONTRACTOR

29. CONTRACTOR?S STATE LIC.

30. ADDRESS

31. BUSINESS TEL. NO

 

32. EMAIL ADDRESS

33. NAME OF PERSON IN CHARGE

34. TITLE

Prevailing Wage Issues (Email statements substantiating the allegation)

35. BRIEF EXPLAINATION OF ISSUES: (Check all applicable boxes)

Non-payment /Underpayment of wages Yes    No
Not paid travel and subsistence Yes    No
Under reporting of hours  Yes    No

Unpaid overtime/Sat/Sun/Holiday rate  Yes    No
Misclassification of worker  Yes    No
Insufficient fund check  Yes    No
Fringe benefits not paid  Yes    No
Other: 

 

Apprentice Occupation

36. Trades and Classifications:

Apprentice Violations 1777.5

37. If the contractor is approved to train- Name of the Apprenticeship Committee:

38. Was there a LABOR COMPLIANCE PROGRAM on this project?  Yes    No

If Yes, Name of the LCP:
LCP Telephone Number:

 

Apprentice Issues

(List any documentation to be provided substantiating the allegation)

39. BRIEF EXPLAINATION OF ISSUES: (Check all applicable boxes)

Failed to provide Contract award information (DAS 140). California Code of Regulations 230 Yes  No
Failed to request dispatch of apprentices (DAS 142). California Code of Regulations 230.1 Yes  No
Failed to employ registered apprentices in the correct ratio or not at all. California Code of Regulations 230.1 Yes No
Failed to make apprenticeship training fund contributions. California Code of Regulations 230.2 Yes  No
Other (give clear concise statement of the facts constituting the basis of your complaint)


  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 (Type Name): 

  Date: 

 


 
 
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