ETA Form 9204 - Pa Registered Apprenticeship Programs Complaint Form

Complaint Form: Registered Apprenticeship Programs	U.S. Department of Labor Employment and Training Administration Office of Apprenticeship
OMB No. 1205-0NEW Expiration Date: XX/XX/XXXX

Instructions: Before completing this form, please read all instructions, including the Privacy Act statement below. Use this form to file a complaint about a violation of the apprenticeship agreement, the Registered Apprenticeship Program’s labor standards (29 CFR part 29), or a complaint of retaliation for exercising a right afforded by an apprenticeship agreement or 29 CFR Part 29 . This form should not be used for complaints alleging Equal Employment Opportunity violations or for complaints relating to a matter covered by a collective bargaining agreement. Complaints ordinarily must be filed within 300 calendar days after the conclusion of the events that gave rise to the dispute or the alleged violation, or, 300 calendar days after the complainant became aware of the alleged violation. However, this deadline may be extended in limited circumstances for good cause. This form constitutes notification that a formal complaint under 29 CFR part 29 is being filed with the Program Sponsor or Registration Agency.

Anonymous complaints: This form may be used to file an anonymous complaint. Anonymous complaints must be filed with the Registration Agency in the first instance (i.e., a complaint cannot be filed anonymously with a Registration Agency if the complaint was previously filed or raised with the Program Sponsor). Complaints alleging retaliation cannot be filed anonymously. Complainants who wish to file anonymously may omit their name, address, and signature below. Anonymous complainants may omit their contact information if the contact information for an authorized representative is provided.

Privacy Act Notice: The Privacy Act of 1974 requires that the USDOL provide the following statements to each individual from whom it requests information.

The authority for collecting this information is the National Apprenticeship Act of 1937.

The submission of this information is voluntary.

The information is used to process complaints under the above Act.

Non-Retaliation: Federal (Office of Apprenticeship, “OA”) regulations require sponsors and employers to take all necessary steps to assure that there is no retaliation against any person who opposes a violation, alleges a violation, or participates in the investigation of an alleged violation of 29 CFR part 29 or an apprenticeship agreement. This includes any intimidation, threat, coercion, or discrimination. Please notify the Registration Agency immediately if any alleged attempt at retaliation is made and file a Complaint Form.

SUMMARY OF COMPLAINT
Briefly describe the violation(s) the apprenticeship agreement or the Registered Apprenticeship Program’s labor standards that you believe exist.
On what date(s) did the alleged violation(s) occur?
Is the alleged violation(s) ongoing?						▢ Yes		▢ No
Have all the events giving rise to the alleged violation(s) concluded?						▢ Yes		▢ No
Indicate the name(s) and title(s) of the person(s) or entity(s) involved:
Indicate the location of the alleged violation(s):
ANONYMOUS COMPLAINT
Complainants have the right to make anonymous complaints. A complaint cannot be anonymous if the complaint was already made with a Program Sponsor or if the complaint relates to retaliation. To make an anonymous complaint, complete the rest of this section and skip the Contact Information section below.
Have you previously filed or raised this complaint with the Program Sponsor?						▢ Yes ▢ No
Is your complaint about retaliation?						▢ Yes ▢ No
If you answered “no” to the last two questions, do you wish to file your complaint anonymously?						▢ Yes ▢ No
Name of Authorized Representative:
Telephone:
CONTACT INFORMATION
If you are comfortable revealing additional identifying information, please answer the following questions. To the extent permitted by law, your name and address will not be disclosed.
Name of Complainant:
Street Address:
City:
State:					Zip Code:
Telephone:
Email Address:
Name of Authorized Representative:
Telephone:
Apprenticeship Program Sponsor:
Street Address:
City:
State:					Zip Code:
Signature of Complainant or Authorized Representative:							Date:

Please mail or scan and email your complaint and any relevant supporting documents to the Registration Agency that registered the apprenticeship program to which your complaint pertains. A list of Registration Agencies and their contact information is available at https://www.apprenticeship.gov/about-us/apprenticeship-system.

The collection and maintenance of the data on ETA Form-9204, Complaint Form – Registered Apprenticeship Programs, is authorized under the National Apprenticeship Act, 29 U.S.C. 50, and its implementing regulations at 29 CFR part 29. The data is used for apprenticeship program statistical purposes and is maintained, pursuant to the Privacy Act of 1974 (5 U.S.C. 552a.). Data may be disclosed to a State Apprenticeship Agency to determine an assessment of skill needs and program information, and in connection with federal litigation or when required by law.

Public Burden Statement: Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. Public reporting burden for this collection of information, which is voluntary, is estimated to average thirty minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the information. While use of this form is optional, a fully completed ETA Form 9204 provides the information required by 29 CFR part 29 to request an investigation of your complaint.  The regulations require that all Registered Apprenticeship Program complaints be in writing. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Employment and Training Administration, Office of Apprenticeship, Room C-5321, Washington, D.C. 20210 or email OA-ICRs@dol.gov and reference OMB Control Number 1205-0NEW.

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ETA Form 9204