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

Migrant and Seasonal Agricultural Worker Protection Act

U.S. Department of Labor

Wage and Hour Division

Worker Information—Terms and Conditions of Employment

OMB NO: 1235-0002

Expires: XX/XX/XXXX

1. Place of employment (with as much specificity as practical, such as the name and address of the employer or association): ______________

________________________________________________________________________________________________________________

2. Period of employment: From To

3. Wage rates to be paid: $ per Hour Piece Rate $ per

Additional details about pay (e.g., overtime rates, bonuses, etc.): _____________________________________________________________

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. Other benefits: Charge(s)

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 that 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 WH516 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.

REV XX/XX

We estimate that it will take an average of 32 minutes to complete this collection of information, including the time to review instructions, search existing data sources, gather and maintain the data needed, and complete and review 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 S3502, 200 Constitution Avenue NW, 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 WH516 ENG}