Form 301 Request for Assistance From Department of Labor, EBSA

PROPOSED WEB INTAKE FORM

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[SCREENS THAT FOLLOW ARE SEEN WHEN THE Privacy Information or
Paperwork Reduction Act Information LINKS ARE CLICKED]
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If General Information button is clicked:

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If Printable Mail-in Form button is clicked:

The form comes up in a version that can be printed, and the field office address related to
the inquirer’s zip code is automatically shown on the form:

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COMPLETED EXAMPLE of PROPOSED FORM

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After Submit button is selected:

If selected documents to upload, after Exit:

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For security reasons, user must re-enter telephone number to upload.

Upload screen:

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