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
Explain the nature of your complaint and why you believe there may be a violation of the law.
List all minor employees. Include the name or initials and, if known, the address, phone number, age, date of birth, and job position:		Please limit to 2500 characters or less.

Employer Information
First Name of Contact Person:			Company Name:	*
Initial:			Telephone:	*
Last Name of Contact Person:			Address - Line 1:	*
E-Mail:			Address - Line 2:
First Name of Owner:			City:	*
Initial:			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
Last Name of Owner:	*		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?

YES  NO

Violations
1. Do they employ anyone under 14 years old?	*	YES  NO
If yes, explain:	*
2. Do minors work with an official work permit?:	*	YES  NO
3. Do minors work more than eight hours in a day?	*	YES  NO
4. Do minors work what could be considered an excessive number of hours per week?	*	YES  NO
If yes, explain:	*
5. Are minors employed under age of 18 years old?	*	YES  NO
6. Do minors work in a hazardous occupation or under dangerous conditions?	*	YES  NO
If yes, please explain	*
7. Do minors work more than five hours without a 30-minute break?	*	YES  NO
If yes, please explain:	*
8. Do minors work late at night?	*	YES  NO
If Yes, please explain::	*
9. Do minors work during very early or unusual hours in the morning?	*	YES  NO
If yes, please explain:	*
10. Explain any additional information that may be useful for the investigation of this complaint:
Please limit to 2500 characters or less.

NOTE: I hereby declare that, to the best of my knowledge and belief, the above information is a truthful statement of the facts related to the alleged violation(s) of the Pennsylvania Child Labor Law.

The office staff will contact you to obtain more information. Notify the office if your contact address or phone number changes.

The information shared in this complaint form is confidential.

We do not inquire about immigration status.

Auxiliary aides are available by request to individuals with disabilities.