Department of Labor & Industry - Bureau of Labor Law Compliance - Child Labor Act Complaint

This form is used for complaints under the Pennsylvania Child Labor Act of 2012, P.L. 1209, No. 151.

Claimant Information
First Name:	*		Daytime Telephone:
Initial:			Evening Telephone:
Last Name:	*		FAX:
Address - Line 1:	*		E-Mail:
Address - Line 2:
City:	*
State:	*	---Select--- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code:	*

Minor Information
Enter information relating to the involved Minor(s) (under the age of 18) in the area provided below.
Include Name, Address, Telephone Number, Age and/or Date of Birth (if known).

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:	*	---Select--- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
			Zip Code:	*
			County:		---Select--- None Adams Allegheny Armstrong Beaver Bedford Berks Blair Bradford Bucks Butler Cambria Cameron Carbon Centre Chester Clarion Clearfield Clinton Columbia Crawford Cumberland Dauphin Delaware Elk Erie Fayette Forest Franklin Fulton Greene Huntingdon Indiana Jefferson Juniata Lackawanna Lancaster Lawrence Lebanon Lehigh Luzerne Lycoming McKean Mercer Mifflin Monroe Montgomery Montour Northampton Northumberland Perry Philadelphia Pike Potter Schuylkill Snyder Somerset Sullivan Susquehanna Tioga Union Venango Warren Washington Wayne Westmoreland Wyoming York Out of State

Do you wish to remain anonymous?

YESNO

Violations
1. Are minors employed under the age of 14 years old?	*	YESNO
If Yes, please explain:	*
2. Are minors employed with working papers officially called Employment Certificates?:	*	YESNO
3. Are minors employed more than 8 hours a day?	*	YESNO
4. Are minors employed in what may be excessive hours per week?	*	YESNO
If Yes, please explain:	*
5. Are minors employed under age of 18 years old?	*	YESNO
6. Are minors employed in a prohibited occupation?	*	YESNO
If Yes, please explain:	*
7. Are minors employed more than 5 hours without 30 min. 'Break'?	*	YESNO
If Yes, please explain:	*
8. Are minors employed late at night; either during school or summer vacation?	*	YESNO
If Yes, please explain::	*
9. Are minors employed during very early or odd hours of the morning?	*	YESNO
If Yes, please explain:	*
10. Please explain any additional needed information which may be helpful to complete the investigation of this complaint.

I hereby certify that to the best of my knowledge and behalf, the above information is a true statement of facts relating to the alleged Violation(s) of the Child Labor Act of the Commonwealth of Pennsylvania. The Bureau will contact you for any further information. Please notify the Bureau if there is a change of address or telephone by which to contact you.