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

U.S. Department of Labor

Migrant and Seasonal Agricultural
Worker Protection Act

Wage and Hour Division
OMB Control Number: 1235-0002
Expires: xx/xx/xxxx

Worker Information – Terms and Conditions of Employment
1. Place of Employment: __________________________________________________________________________________________________
2. Period of Employment:

From __________________________

3. Wage rates to be paid: $_____________________ per Hour

To ______________________________
Piece Rate $ ___________________ 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 insurance carrier: _____________________________________________________________________________________________
Name and address of policyholder(s): _____________________________________________________________________________________
___________________________________________________________________________________________________________________
Name 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. Other benefits: ________________________________________________________________ Chaj (yo) ______________________________
9. For migrant workers who will be housed, the kind of housing available 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 benefits 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 workers. 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
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have any comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, send them to the
Administrator Wage and Hour Division , Room S-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. June 2011