Free PUBLIC COMPLAINT REFERAL - Arizona


File Size: 15.6 kB
Pages: 2
File Format: PDF
State: Arizona
Category: Workers Compensation
Author: DeborahB
Word Count: 197 Words, 1,533 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.ica.state.az.us/forms/complaint/youthEmploymentPublich.pdf

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Preview PUBLIC COMPLAINT REFERAL
INDUSTRIAL COMMISSION OF ARIZONA
LABOR DEPARTMENT P. O. Box 19070 Phoenix, Arizona 85005 542-4515
PUBLIC COMPLAINT REFERRAL REPORT
1. 3. Date: Business Name: Corporation : 2. CL No.: Franchise:

4. 5. 7

Address: City: Type of Business:

State: 6.

Phone: Zip Code: Number of Employees:

9

12.

Ownership: 8. Name of Principals (s) Corporation Sole Owner(s): _ ______________________ Proprietorship Manger(s): _______________________ Government Agency Supervisor: Franchise Partnership . Referred by: Compliance 10. Date Received: ____________________________________ ADOSH Other Govt. _____________________________________________________ Agency 11. Type of Contact: Field Visit Compliance Legal Dept. Citizen Telephone Letter Other Special Fund Media Possible violation description (Include specifics, e.g. name (s) and age (s) of youth (s), work site, type of possible violation, etc.):

Youth' Name: s Address: Work Phone No.: Duties: 13 . Occupation Violation: Imminent Danger Other There

Age: City: Home Phone No.:

D.O.B. State:

Zip Code:

Serious No Longer

14. Hours Violation: Very Serious Other There

Serious No Longer

15.

Potential Witness (es) (Include name, location, affiliation, telephone number): Name: Address: City: State: Work Phone No.: Home Phone No.: Inspection Planned? Yes Send letter? With Yes Other Information: No 20. Date: Take No 17. If yes, priority?

Anonymous (Keep confidential)

Zip Code:

16.

18. If no, reason?

19.

21 Response due:

22.

23.

Investigator: Date:

24. Supervisor: Date: