Please fill out the form as completely as possible. Please attach additional sheets of paper if more explanation is needed for any of the questions.

Date:

Employee Name:*

Employee Address:

Employee Phone Number:*

Employee Email:

Preferred Language:

Business Name:*

Business Owner or Manager:

Business Address

Business Phone Number:

Business Email:

Have you worked at least 2 hours in a calendar week in Emeryville, California?

Yes

No

Why you are submitting this complaint? Check all that apply.

I’m not being paid the required minimum compensation. (Please fill out Sections A & D) I’m not receiving or being allowed to use sick leave. (Please fill out Sections B & D) I am not receiving my service charges from my hospitality employer.

I have been subject to retaliation for exercising my rights under the City’s Minimum Wage and Paid Sick Leave ordinance. (Please fill out all Sections) Other

If Other (Please fill out all Sections and provide a brief description):

SECTION A: Compensation

1. What is your position or description of your duties (e.g. driver, cook, etc.)?

2. When did you begin work for this employer?

3. Are you still employed by this employer?

Yes

No.

If NO, when was your last day of work?

Why are you no longer working for this employer?

4. Who sets your schedule and supervises your work?

5. Do you have records of the hours you work?

Yes

No

6. Are you required to record your start and end time for each period of work?

Yes

No

If YES, how are the hours you work recorded (examples: punch in and out on a time clock, self-completed time sheet/time card)?

If NO, explain how your hours are tracked.

7. What is your current rate of pay per hour?

8. Have you been properly paid for all hours worked?

Yes

No

If NO, please specify the period of time you were not properly paid.

9. Do you have any pay stubs or receipts?

Yes. If YES, please attach copies of pay stubs/receipts for the period during which you believe you were not receiving proper payment.

No. If NO, please attach copies of any documentation you have showing the payment you have received and hours you have worked.

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SECTION B: Paid Sick Leave

1. How much sick leave has been made available to you working for this employer since July 2, 2015 or your hire date, whichever is later?

2. Do you have a spouse or registered domestic partner?

Yes

No

3. If you do not have a spouse or domestic partner, has your employer provided you with an opportunity to designate another individual for whom you can use your sick leave to provide care?

Yes

No

If YES, please specify when you were denied sick leave and the reason the employer provided for denying your request.

SECTION C: Hospitality Service Charges

If you work for a hospitality employer, has your employer provided you with written notification of service charge distribution?

Yes

No

If YES, please attach a copy of the service charge distribution.

2. Have you received your share of the service charge?

Yes

No

If NO, please specify the dates you were not properly paid.

SECTION D: General

1. Are you a member of a union?

Yes

No

If YES:

(a) What is the name of your union?

(b) Has your union waived all or a portion of Emeryville’s Minimum Wage and Paid Sick Leave Ordinance?

Yes No

I donn't know

(c) What is the name of your business agent/union rep?

(d) If available, please attach a copy of the collective bargaining agreement/union contract

2. Have you ever complained or asked your employer questions about your pay or benefits?

Yes

No

If YES, please provide the date of your inquiry/complaint, the name and title of who you talked to and their response.

3. Has your employer ever retaliated against you for raising issues about your pay or benefits?

Yes

No

If YES, please describe what happened.

4. Do you wish to keep this complaint anonymous? (Keep your name confidential from your employer)

Yes, I want to keep this complaint confidential.

No, it is OK for my employer to know I submitted this complaint.

5. How many employees work for your employer in Emeryville?

6. Do you have anything else to add? If so, please attach copies of any documentation to substantiate your claim, such as written communication from employer, statement of benefits, etc.

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