Compliance Tracking System (CTS)

Act 102 Complaint
Department of Labor & Industry - Bureau of Labor Law Compliance - Prohibition of Excessive Overtime in Health Care Complaint
This form is used for complaints under the Pennsylvania Act 102
Claimant Information
First Name: * Daytime Telephone:
Initial: Evening Telephone:
Last Name: * Fax:
Address - Line 1: * E-Mail:
Address - Line 2: Are you involved in direct patient care or clinical services? *
City: * Are you hourly employee? *
State: * Do you supervise?: *
Zip: * Occupation and job title: *
Briefly describe your job duties: *
Employer Information
First Name of Contact Person: * Company Name: *
Initial: Telephone:
Last Name of Contact Person: * Address - Line 1: *
First Name of Owner: * Address - Line 2:
Initial: City: *
Last Name of Owner: * State: *
Zip: *
County: *
Establishment Code:
Additional Employer Information
What type of care does your employer provide? *
Name of your supervisor or individual who requested that you work overtime: *
Phone number of supervisor: *
if available, direct telephone extension for supervisor:
Act 102 Complaint Details
Provide the date, hours originally scheduled to work, and the overtime hours worked for each time you had to work mandatory overtime. Include additional sheets if necessary.
Original Schedule Shift(s): *
Mandatory Overtime: *
1. Did you volunteer to work overtime? *
If Yes, please explain: *
2. Did you agree to be on call? *
If Yes, please explain: *
3. a) At or before the time overtime was requested, were you participating in any procedure? *
3. b) Could your absence have had an adverse effect on the patient? *
If Yes, please explain: *
Did your employer explain the reason for mandatory overtime? *
If Yes, please explain: *
5.To your knowledge, was the overtime required due to any of the following?
a) Unforseen circumstance? *
b) Vacancies resulting from chronic staff shortages? *
c) A national, state or municipal emergency or other emergency? *
If Yes, please explain: *
6.To your knowledge, did your employer do any of the following?
a) Ask for volunteers to work overtime? *
b) Contact per diem staff? *
c) Contact a temporary agency? *
d) Provide you with up to one hour to arrange care for children or disabled family members? *
e) Provide you with any documentation concerning efforts to obtain staffing? *
If Yes, please explain: *
If you are aware of any potential witness the Bureau may contact during this investigation, please provide information here: *
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I verify that facts set forth in this complaint are true and correct to the best of my knowledge, information and belief, I sign this complaint subject to 18 Pa.C.S. 4904(relating to unsworn falsifications to authorities)