Record Of Employee Interview {HUD-11}

CONFIDENTIALRecordofEmployeeInterview U.S.DepartmentofHousing andUrbanDevelopmentOfficeofLaborRelationsOMB Approval No. 2501-0009(exp./3/201)Publicreportingburdenforthiscollectionofinformationisestimatedtoaverage15minutesperresponse,includingthetimeforreviewinginstructions,searchingexistingdatasources,gatheringandmaintainingthedataneeded,andcompletingandreviewingthecollectionofinformation.Thisagencymaynotcollectthisinformation,andyouarenotrequiredtocompletethisform,unlessitdisplaysacurrentlyvalidOMBcontrolnumber.TheinformationiscollectedtoensurecompliancewiththeFederallaborstandardsbyrecordinginterviewswithconstructionworkers.TheinformationcollectedwillassistHUDintheconductofcompliancemonitoring;theinformationwillbeusedtotesttheveracityofcertifiedpayrollreportssubmittedbytheemployer.SensitiveInformation.TheinformationcollectedonthisformisconsideredsensitiveandisprotectedbythePrivacyAct.ThePrivacyActrequiresthatthese recordsbemaintainedwithappropriateadministrative,technical,andphysicalsafeguardstoensuretheirsecurityandconfidentiality.Inaddition,theserecordsshouldbeprotectedagainstanyanticipatedthreatsorhazardstotheirsecurityorintegritythatcouldresultinsubstantialharm,embarrassment,inconvenience,orunfairnesstoanyindividualonwhomtheinformationismaintained.Theinformationcollectedhereinisvoluntary,andanyinformationprovidedshallbekeptconfidential.1a.ProjectName2a.EmployeeName 1b.ProjectNumber2b.EmployeePhoneNumber(includingareacode) 1c.ContractororSubcontractor(Employer)2c.EmployeeHomeAddress&ZipCode 2d.Verificationofidentification?Yes No 3a.Howlongonthisjob?3b.Lastdateonthisjobbeforetoday?3c.No.ofhourslastdayonthisjob?4a.Hourlyrateofpay?4b.FringeBenefits?4c.Paystub? VacationYes No Yes No MedicalYes No PensionYes No 5.Yourjobclassification(s)(listall)---continueonaseparatesheetifnecessary 6.Yourduties 7.Toolsorequipmentused YNYN 8.Areyouanapprenticeortrainee? 10.Areyoupaidatleasttimeand275forallhoursworkedinexcessof40inaweek? 9.Areyoupaidforallhoursworked? 11.Haveyoueverbeenthreatenedorcoercedintogivingupanypartofyourpay? 12a.EmployeeSignature12b.Date 13.DutiesobservedbytheInterviewer(Pleasebespecific.) 14.Remarks 15a.Interviewername(pleaseprint)15b.SignatureofInterviewer15c.Dateofinterview PayrollExamination16.Remarks 17a. SignatureofPayrollExaminer 17b. Date PreviouseditionsareobsoleteForm HUD-11 (0/20) American LegalNet, Inc. www.FormsWorkFlow.com