Form WH-516-ENGLISH Worker Information-Terms and Conditions of Employment

Migrant and Seasonal Agricultural
Worker Protection Act

SIIHD

U.S. Department of Labor
Wage and Hour Division

u.s. Wage and Hour DivIsion

OMB No.: 1235-0002

Expires: 05/31/2011

Worker Information -Terms and Conditions of Employment
1. Place of employment: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
2. Period of employment:

From _ _ _ _ _ _ _ _ _ __

To _____________________

3. Wage rates to be paid:

$

Piece Rate $ _ _ _ _ _ _ __

per Hour

per _ _ _ _ _ _ _ __

4. Crops and kinds of activities: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
5. Transportation or other benefits, 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 notified to file claim: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Deadline for filing claim: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
7. Unemployment compensation insurance provided:

Yes __________

No _____________

8. 0therbenefits: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Charge(s) __________

9. For migrant workers who will be housed, the kind of housing a vailable 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 which have been made with establishment owners or agents for the payment of a commission or other bene fits 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 VtOrkers. Contact the nearest office of the Wage
and Hour Division to obtain such forms.
While completion of Form WH-516 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 for reviewing instructions, search
Eoosting data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you ha va any
comments regarding this burden estimate or any other aspect of this collection of information, including s.uggestions for reducing this burden, send
them to the Administrator Wage and Hour Division, Room 5-3502, 200 Constitution A venue, N.w., 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 WH-516 English

Rev. Sept. 2010