HTML Preview Employee Contract Complaint page number 1.
Form OCC3, Rev. 05/14
CITY OF LOS ANGELES
Department of Public Works
Bureau of Contract Administration
Office of Contract Compliance
EMPLOYEE COMPLAINT FORM
(Please print clearly)
Project Name:
Project Location:
Employing Contractor:
Name of Supervisor:
EMPLOYEE DATA
(The information written on this form is completely confidential)
Your Name: Social Security No. (Last 4 digits):
Address:
Phone Number(s) Email Address (if available):
Hourly Rate Paid $ Overtime Rate Paid $
Fringe Benefits Paid? Yes No If yes, how much? $
Date Hired: Date Laid Off/Terminated (if applicable): Shift(s) Hours:
Craft(s) Performed:
Union Member? No Yes, Local #
Employee Complaint (Use additional pages if more space is needed):
I hereby certify that the above information is true and correct to the best of my knowledge.
____________________________________________ _____________________________________
Employee’s Signature Date
Please send or fax the signed copy of this compliant to: Office of Contract Compliance
1149 South Broadway Street, Suite 300
Los Angeles, CA 90015
Fax: (213) 847-2777
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