LB-0803 word version
Tennessee Department of Labor and Workforce Development LOCAL OFFICE:
CERTIFICATION SERVICES QUARTER:
Service to Migrant and Seasonal Farmworkers Report Worksheet
A. Outreach Services REPORT PERIOD
1. Best estimate of MSFWs in your area 0
2. Number of contacts with persons who were MSFWs 0
3. Number of staff days TDLWD staff performed outreach 0
4. Number of MSFW contacts by cooperating agency staff 0
5. Approximate staff days cooperating agency staff performed outreach 0
B. Referral of Apparent Violations to Enforcement
1. To ESA 0
2. To OSHA 0
3. To Other 0
C. Agricultural Clearance Orders
1. Number of orders on which violations were found 0
a. Number of orders on which violations were corrected through formal resolution 0
b. Number of orders having violations which were referred to enforcing agency
1. To ESA 0
2. To OSHA 0
3. To Other 0
2. Number of employers for whom discontinuation of service proceedings were
initiated as a result of a field check 0
D. USES Complaint System
1. Total Complaints Received 0
a. TDLWD-related 0
(1) Non-MSFW 0
(2) MSFW 0
(a) H-2A 0
(b) Non H-2A 0
b. Non TDLWD-related
(1) Non-MSFW 0
(2) MSFW 0
ESA OSHA OTHER
2. Number of MSFW TDLWD-related complaints referred to: 0, 0, 0
3. Number of Non-MSFW TDLWD-related complaints referred to: 0, 0, 0
4. Number of MSFW Non-TDLWD related complaints referred to: 0, 0, 0
5. Number of MSFW TDLWD-related complaints unresolved after 45 days: 0, 0, 0
A. OUTREACH SERVICES
1. Best Estimate of MSFWs in your area: Enter the best estimate of the peak number of MSFWs in the Field office area
during the reporting period.
2. Number of contacts with persons who were MSFWs: Enter the number of persons who are MSFWs and were
contacted by TDLWD during the outreach this reporting period. A MSFW who is provided service or information
more than once can be counted more than one time.
3. Number of staff days TDLWD staff performed outreach services to MSFWs: Round off hours to the nearest quarter
of a staff day. For example, 7.5 of outreach would be rounded off to one staff day. Round twelve hours of outreach
to 1 ¼ staff day.
4. Number of MSFW contacts by cooperating agency staff: Enter the number of MSFWs who were contacted and
provided with information on all available services by cooperating agency outreach.
5. Approximate staff days cooperating agency staff performed outreach: Enter the number of staff days cooperating
agency staff reported performing TDLWD outreach to MSFWs. Include only outreach performed by groups which through
written or other arrangements with the TDLWD provided MSFWs with verbal and/or written explanations of all available
TDLWD services and with referral to these services. Round off figures to the nearest whole number.
B. REFERRAL OF APPARENT VIOLATIONS TO ENFORCEMENT AGENCIES: This section covers the referral of
suspected violations of employment-related laws to enforcement agencies. Enter the number of apparent violations to:
(1) ESA, (2) OSHA, and (3) OTHER
C. AGRICULTURAL CLEARANCE ORDERS: This section covers agricultural clearance orders and violations found through
the field check process. Field checks will be conducted on a significant number of agricultural work sites to which TDLWD
placements have been made through the interstate or intrastate clearance system (20 CR 653.503). Exclude h-2A orders.
The Employment Standards Administration (ESA) will conduct field checks on H-2A orders.
1. Enter the number of orders on which violations were found.
a. Enter the number of orders on which violations were corrected through informal resolution.
b. Enter the number of orders having violations which were referred to : (1) ESA, (2) OSHA, or (3) OTHER
2. Enter the number of employers for whom discontinuation of service proceedings were initiated this reporting
period as a result of a field check.
D. USES COMPLAIN SYSTEM: This section provides data on the effectiveness of the State agency complaint system
established according to 20 CFR 658, Subpart E. Due to special requirements in the regulations, complaints are also reported
separately by MSFW and non-MSFW designations.
1. TOTAL COMPLAINTS RECEIVED: Enter the total number of complaints received for this reporting period. The combined
total of a. and b. should equal this count.
a. TDLWD-RELATED: Enter the number of the following complaints received for this period.
(1) Non-MSFW, Non-TDLWD-Related (2) MSFW, Non-TDLWD-Related (a) H-2A (b) Non H-2A
b. NON-TDLWD-RELATED: Enter the number of following complaints:
(1) Non-MSFW, Non-TDLWD-Related (2) MSFW, Non-TDLWD-Related
2. NUMBERS OF MSFWs-RELATED COMPLAINTS REFERRED: Enter the number of MSFW, TDLWD-related complaints
that were referred this reporting period to enforcement agencies under ESA, OSHA, OTHER.
3. NUMBER OF NON-MSFWs-RELATED COMPLAINTS REFERRED: Enter the number of Non-MSFW, TDLWD-related
complaints that were referred this reporting period to enforcement agencies under ESA, OSHA, and OTHER.
4. NUMBER OF MSFW NON-TDLWD RELATED COMPLAINTS REFERRED TO: ESA, OSHA, OTHER
5. NUMBER OF MSFW TDLWD-RELATED COMPLAINTS UNRESOLVED: Enter the number of MSFW, TDLWD-related
complaints for this reporting period that have been unresolved after complaints. A complaint by the State agency or
enforcement agency.
LB-0803 word version 12/2007