Work Period Statement Policy
Please complete this form regarding your recent work period. Your responses will remain confidential.
Employee Information
Please provide your details and work period dates below.
Employee Name
*
First Name
Last Name
Work Period Start Date
*
-
Month
-
Day
Year
Date
Work Period End Date
*
-
Month
-
Day
Year
Date
Have you been injured, harassed or discriminated against at work during this work period?
*
Yes
No
Have you witnessed anyone getting injured, harassed or discriminated against at work during this work period?
*
Yes
No
Were you denied or unable to take proper break times and meal times under California labor law during this work period?
*
Yes
No
Have you witnessed that anyone did not receive their break times and meal times under California labor law at work during this work period?
*
Yes
No
Were there any inaccuracies or missing payments in your paycheck, including overtime (if applicable), during this work period?
*
Yes
No
Additional comments concerning the above answers (optional)
Your answers shall be kept confidential. I fully and freely took my paid rest breaks and unpaid meal breaks during my work period pursuant to the California labor law and this wage payment to me is accurate.
Date (Employee)
*
-
Month
-
Day
Year
Date
Employee Signature
*
Submit Statement
Submit Statement
Should be Empty: