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Child Labor Complaint Form
*
Indicates Required Field
*
Does this complaint/concern involve an individual 16 years of age or older?
--Select One
Yes
No
Unknown
*
Do you believe the workplace/business is placing the child in immediate danger of injury?
--Select One
Yes
No
Unknown
If this complaint/concern involves an individual 16 years of age or older, please contact the US Department of Labor at ________
Contact Information
__________________________________________
*
First Name
*
Last Name
*
Address
*
City
*
State
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*
Zip Code
(no dashes e.g. 555554444)
*
Phone Number
(no dashes e.g. 5554443333)
Email Address
Child Employee Information
_____________________________________________________________________________
*
Are you the parent of this child?
Yes
No
*
Child's Name
*
Child's Address
*
Child's City
*
State
Select State
AA
AE
AK
AL
AO
AP
AR
AS
AZ
CA
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
JP
KS
KY
LA
MA
MD
ME
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UE
UT
VA
VI
VT
WA
WI
WV
WY
Zip Code
(no dashes e.g. 555554444)
Child's Phone Number
(no dashes e.g. 5554443333)
Child's Email
Child's Employer Information
_____________________________________________________________________________
*
Business Name
*
Business Address
*
Business City
*
Business State
Select State
AA
AE
AK
AL
AO
AP
AR
AS
AZ
CA
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
JP
KS
KY
LA
MA
MD
ME
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UE
UT
VA
VI
VT
WA
WI
WV
WY
Business Phone Number
(no dashes e.g. 5554443333)
*
Type of Business
*
Owner/Supervisor Name
Complaint Information
__________________________________________
*
Nature of Complaint
Age
No Work Permit
Hours
Time(s)
Break(s)
Prohibited Occupation
Other
Date Incident Occurred
(Format: mm/dd/yyyy)
Location of Violation/Incident
*
Please provide a detailed statement of your complaint/concern in the space below which includes the nature, circumstances and date(s) of the alleged violations.
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