labor_form_guidance | California
California Pay Transparency Complaint form
Summary
California Pay Transparency Complaint form
Text
STATE OF CALIFORNIA – DEPARTMENT OF INDUSTRIAL RELATIONS
Pay Transparency Complaint
DIR DLSE 001 (Rev. 04/2024)
FOR OFFICE USE ONLY
Taken by: Office: Intake Employee Name:
PLEASE PRINT OR TYPE ALL INFORMATION
Refer to the accompanying Instructions to assist you in
filling out this form.
Date filed: Violation: Case #:
Action: NAICS / SIC #:
The following questions seek information that may assist in the investigation of the complaint. Missing or incomplete
information in the REQUIRED sections will cause the complaint to be returned for incomplete information.
Y
our complaint is confidential. You will be contacted onl y if there is a need for additional information, or if the re is a need
to reveal your identity in order to conti nue the investigation. No status updates on the investigation will be provided.
Part 1 REQUIRED: PRELIMINARY QUESTIONS
1. What type of Pay Transparency Violation are you reporting?
I am reporting a job posting without a pay scale or salary or hourly wage range that may violate Labor Code
section 432.3(c)(3) or 432.3(c)(5)
I first learned of the job posting on (MM/DD/YYYY)
The job was posted on (Mark all that apply):
Employer’s website
Job posting emailed by employer or third party
Website that advertises job postings for multiple employers
Other job posting method:
I am reporting an employer that sought salary history information about an applicant for employment and/or
relied on the salary history information of an applicant for employment as a factor in determining whether to
offer employment or what salary to offer the applicant.
I am reporting an employer that failed to provide the pay scale for a position upon request to an applicant
applying for employment, or to an employee for the position in which the employee is currently employed.
2. Provide a detailed account of the violation:
If you do not wish to report a Pay Transparency Violation: STOP HERE, DO NOT FILL OUT THIS FORM.
Part 2 REQUIRED: EMPLOYER INFORMATION
3. EMPLOYER / BUSINESS NAME(S) 4. WEBSITE ADDRESS 5. EMPLOYER’S PHONE
6. ADDRESS of EMPLOYER / BUSINESS CITY STATE ZIP CODE
7. Does the employer have 15 or more employees? 8. TYPE OF BUSINESS
YES NO I DON’T KNOW
Part 3 REQUIRED: JOB INFORMATION
9. JOB TITLE/POSITION LISTED ON JOB POSTING 10. NAME OF CONTACT PERSON
11. CONTACT PERSON’S PHONE 12. EMAIL ADDRESS OF CONTACT PERSON
Page 1 of 3
FOR OFFICE USE ONLY
Case#:
STATE OF CALIFORNIA - DEPARTMENT OF INDUSTRIAL RELATIONS
Pay Transparency Complaint
DIR DLSE 001 (Rev. 04/2024)
PRINT EMPLOYER’S NAME:
Part 4 REQUIRED: YOUR INFORMATION
13. Your FIRST NAME 14. Your LAST NAME
15. Your HOME PHONE 16. Your OTHER PHONE 17. Your BIRTH DATE (MM/DD/YYYY)
18. Your MAILING ADDRESS CITY STATE ZIP CODE
19. Your EMAIL ADDRESS
20. Have you filed, or are you filing, other claims against this employer with the Labor Commissioner?
YES, on: (MM/DD/YYYY); Case Number: ;
in District Office:
NO If you have unpaid wages, need to file a retaliation or Equal Pay Act complaint, or would
like to report a labor law violation, please visit our website: WWW.DIR.CA.GOV/DLSE.
21. Have you ever worked for the employer listed in Part 2?
NO YES, I am a current employee YES, I am a former employee
Date of Hire: (MM/DD/YYYY); Date Employment Ended: (MM/DD/YYYY)
Job Title at time of the pay transparency violation:
22. At the time of the violation alleged in Part 1, were you an applicant for employment with the employer listed in
Part 2?
NO
YES, I applied for the following position with the company:
on or about (MM/DD/YYYY) How did you apply for the position:
YES, I was seeking employment with the employer. I did not apply for a position with the company because:
Part 5: LANGUAGE ASSISTANCE & REPRESENTATION
24. If you checked “YES”to Box 23, enter language needed:
YES NO
25. If you are being helped with your claim by a lawyer or other advocate, enter your
26. ADVOCATE’S EMAIL 27. ADVOCATE’S PHONE
28. ADVOCATE’S MAILING ADDRESS CITY STATE ZIP CODE
23. Do you need an interpreter?
ADVOCATE’S NAME and ORGANIZATION:
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STATE OF CALIFORNIA - DEPARTMENT OF INDUSTRIAL RELATIONS
Pay Transparency Complaint
DIR DLSE 001 (Rev. 04/2024)
PRINT EMPLOYER’S NAME:________________________________________
Part 6: OTHER WITNESSES
FOR OFFICE USE ONLY
Case#:
29. Please list any witnesses who can support your claim.
Name: Title:
Address:
Witness Phone Number: Witness Email Address:
Describe what they witnessed or have personal knowledge of relevant to your complaint:
Name: Title:
Address:
Witness Phone Number: Witness Email Address:
Describe what they witnessed or have personal knowledge of relevant to your complaint:
Part 7 REQUIRED: JOB POSTING ATTACHMENT
30. If you are reporting a job posting without a pay scale or salary or hourly wage range, please select the box
that identifies the method in which you are submitting proof of the violation.
I am including a paper copy of the posting with this Pay Transparency Complaint and mailing the complaint
to the Labor Commissioner's District Office.
I am including a paper copy of the posting with this Pay Transparency Complaint and filing it in person with
the Labor Commissioner's District Office.
I am including a .pdf copy of the posting with this Pay Transparency Complaint and emailing it to
[email protected]
The posting attachment does not apply. My complaint does not regard a job posting without a pay scale or
salary or hourly wage range.
I hereby certify under penalty of perjury that the information I have provided is true to the best of my knowledge
and/or recollection.
Signature: Date:
(MM/DD/YYYY)
Print Name:
I understand that by submitting this complaint electronically, I agree to accept electronic communications
at my email address from the Labor Commissioner’s Office. I understand this means that important
documents, including some notices, will go to my email address. I also agree to update the Labor
Commissioner’s Office if my email address changes.
I prefer to receive all communications by mail instead of electronic communications. I understand this
means that the Labor Commissioner’s Office will send all documents regarding this case to my
mailing address. I also agree to update the Labor Commissioner’s Office if my mailing address
changes.
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STATE OF CALIFORNIA – DEPARTMENT OF INDUSTRIAL RELATIONS Pay Transparency Complaint DIR DLSE 001 (Rev. 04/2024) FOR OFFICE USE ONLY Taken by: Office: Intake Employee Name: PLEASE PRINT OR TYPE ALL INFORMATION Refer to the accompanying Instructions to assist you in filling out this form. Date filed: Violation: …
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Pay Transparency Complaint DIR DLSE 001 (Rev. 04/2024) PRINT EMPLOYER’S NAME: Part 4 REQUIRED: YOUR INFORMATION 13. Your FIRST NAME 14. Your LAST NAME 15. Your HOME PHONE 16. Your OTHER PHONE 17. Your BIRTH DATE (MM/DD/YYYY) 18. Your MAILING ADDRESS CITY STATE ZIP CODE 19. Your EMAIL ADDRESS 20. Have you filed…
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I am including a paper copy of the posting with this Pay Transparency Complaint and mailing the complaint to the Labor Commissioner's District Office. I am including a paper copy of the posting with this Pay Transparency Complaint and filing it in person with the Labor Commissioner's District Office. I am includin…