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HomeMy WebLinkAboutEmployee Interview001 Record of U.S. Department of Housing and Urban Development OMB Approval No. 2501-0009 Employee Interview Office of Davis-Bacon and Labor Standards (exp. 03/31/2028) Public reporting burden for this collection of information is estimated to average 15 minutes per response,including the time for reviewing instructions.searching existing data sources, gathering and maintaining the data needed.and completing and reviewing the collection of information.This agency may not collect this information.and you are not required to complete this form,unless it displays a currently valid OMB control number. The information is collected to ensure compliance with the Federal labor standards by recording interviews with construction workers The information collected will assist HUD in the conduct of compliance monitoring,the information will be used to test the veracity of certified payroll reports submitted by the employer.Sensitive Information.The information collected on this forth is considered sensitive and is protected by the Privacy Act.The Privacy Act requires that these records be maintained with appropriate administrative,technical,and physical safeguards to ensure their security and confidentiality.In addition.these records should be protected against any anticipated threats or hazards to their security or integrity that could result in substantial harts,embarrassment,inconvenience.or unfairness to any individual on whom the information is maintained The information collected herein is voluntary,and any information provided shall be kept confidential. Note: Please ensure responses are legible and easy to read. la. Project Name 2a. Employee's Full Name 5A-921 i-A ca R,. DA 5(o6w iV wis ?Kola R.6+8t7v etsmi416 1 b. Project Number 2b. Employee's Phone Number(including area code)and Email Address clZiii -Pito-FcT L.cE, Xy-2Z,C(� PQov ��ZlOpB 1 c. Contractor or Subcontractor(Employer—not individual's name or 2c. Employee's Home Address&Zip Code supervisor's name) 2d. Verification of identification? Yes a No ❑ 3a. How long on this 3b. Last date on this 3c.Number of hours 4a. Hourly Rate of Pay 4b. Fringe benefits? 4c. Frequency of job and average job before today? last day on this job? Pay weekly hours Medical Yes 1� No ❑ weekly Q worked? Biweekly El�JG-ru•tT' $.7-2 s� Pension Yes�` No ❑ Semi-monthly❑ Other❑ 5. Your Job Classification(s)(list all and continue on a separate sheet if necessary): M 010 Q 6. Your Duties: PA.rt- Ccvc:arc'/t-r.yr$rrE,r CS•"seu. Ccver<!�� 7. Tools or Equipment Used: t&ll Fie,4 7 F,tEsvo FtoAT 10 Y N Y N 8.Are you an apprentice or trainee? ❑ Pt 10.Are you paid at least time and%(1.5x regular hourly rate)for all hours worked in ❑ excess of 40 in a week? 8a. Have you provided a copy of your ❑ apprenticeship certificate? 9.Are you paid for all hours worked? V ❑ 11. Have you ever been threatened or coerced into giving up any part of your pay? ❑ 12a. 12b. Date 13. Duties Observed by the In erviewer(Please be specific) CbWve1 Qc6asto FDAm"Va Fcfe lcnkr<4 r.sr� /a}� cv ;.gerrr}crgc*�c t*crvcRF�� w!t .�c..r»Q 14. Remarks 15a, Interviewer Name(please print) 15b. Signature of Interviewer 15c. Date of Interview Payroll Examination 16. Remarks 17a. Signature of Payroll Examiner I 17b. Date Previous editions are obsolete Form HUD-11(0312026) Record of U.S. Department of Housing and Urban Development OMB Approval No. 2501-0009 Office of Davis-Bacon and Labor Standards (exp. 03/3112028) Employee Interview 18.Additional Remarks Previous editions are obsolete Form HUD•11(03/2026) Record of U.S. Department of Housing and Urban Development OMB Approval No. 2501-0009 Employee Interview Office of Davis-Bacon and Labor Standards (exp. 03/31/2028) Public reporting burden for this collection of information is estimated to average 15 minutes per response,including the time for reviewing instructions,searching existing data sources, gathering and maintaining the data needed,and completing and reviewing the collection of information.This agency may not collect this information,and you are not required to complete this form,unless it displays a currently valid OMB control number. The information is collected to ensure compliance with the Federal labor standards by recording interviews with construction workers.The information collected will assist HUD in the conduct of compliance monitoring,the information will be used to test the veracity of certified payroll reports submitted by the employer.Sensitive Information.The information collected on this forth is considered sensitive and is protected by the Privacy Act.The Privacy Act requires that these records be maintained with appropriate administrative,technical,and physical safeguards to ensure their security and confidentiality.In addition,these records should be protected against any anticipated threats or hazards to their security or integrity that could result in substantial harm,embarrassment,inconvenience,or unfairness to any individual on whom the information is maintained.The information collected herein is voluntary,and any information provided shall be kept confidential. Note: Please ensure responses are legible and easy to read. 1a. Project Name 2a. Employee's/Full Name ;g'811 L�4+r�s` `� R. -40d SaXvgcK /MP,?o;,t n c V ch 6 Z 1b. Project Number 2b. Employee's Phone Number(including area code)and Email Address coat fli.Le, &`I-ZLAlp � 1 c. Contractor or Subcontractor(Employer—not individual's name or 2c. Employee's Home Address&Zip Code supervisor's name) - 2d. Verification of identification? Yes F0 No ❑ 3a. How long on this 3b. Last date on this 3c.Number of hours 4a. Hourly Rate of Pay 4b. Fringe benefits? 4c. Frequency of job and average job before today? last day on this job? Pay: weekly hours Medical Yes No ❑ weekly E]' worked? Biweekly El;. ,e6 _, -ZS Pension Yes No ❑ Z q Z$' Semi-monthly❑ 4yr-yq 6,W,we' Other❑ 5. Your Job Classification(s)(list all and continue on a separate sheet if necessary): 1i1450,t/ 6. Your Duties: 7. Tools or Equipment Used: �tl F font. 1=12�,�p FccF}7� RQ�tH Y N Y N 8.Are you an apprentice or trainee? ❑ © 10.Are you paid at least time and%(1.5x regular hourly rate)for all hours worked in ❑ excess of 40 in a week? 8a.Have ou provided a copy of your ❑ V apprenti 12b. Date J' J- 15-- 13. Duties Observed by the Interviewer(Please be specific): �SQrV�y1 ✓-t/ renyve%t+S {(aF1 t CC/1 f"f wb.1c ConCr<ft W43 be•^3 Pewr,.d 14. Remarks 15a.. Interviewer Name(please print) 15b. Signature of Interviewer 15c. Date of Interview ^-rry-, Payroll Examination 16. Remarks 17a. Signature of Payroll Examiner 17b. Date Previous editions are obsolete Forth HUD-11(03/2026) Record of U.S. Department of Housing and Urban Development OMB Approval No. 2501-0009 Office of Davis-Bacon and Labor Standards (exp. 03/31/2028) Em to ee Interview 18.Additional Remarks Previous editions are obsolete Form HUDA 1(0312025) Record of U.S. Department of Housing and Urban Development OMB Approval No. 2501-0009 Employee Interview Office of Davis-Bacon and Labor Standards (exp. 03/31/2028) Public reporting burden for this collection of information is estimated to average 15 minutes per response.including the time for reviewing instructions,searching existing data sources, gathering and maintaining the data needed,and completing and reviewing the collection of information.This agency may not collect this information,and you are not required to complete this form,unless it displays a currently valid OMB control number. The information is collected to ensure compliance with the Federal labor standards by recording interviews with construction workers.The information collected will assist HUD in the conduct of compliance monitoring;the information will be used to test the veracity of certified payroll reports submitted by the employer.Sensitive Information.The information collected on this form is considered sensitive and is protected by the Privacy Act.The Privacy Act requires that these records be maintained with appropriate administrative,technical,and physical safeguards to ensure their security and confidentiality.In addition,these records should be protected against any anticipated threats or hazards to their security or integrity that could result in substantial harm,embarrassment,inconvenience,or unfairness to any individual on whom the information is maintained.The information collected herein is voluntary.and any information provided shall be kept confidential. Note: Please ensure responses are legible and easy to read. la. Project Name 2a. Employee's Full Name C -1>96 2 �2 r CRKBS/wtF 0,7. qoVd 310113-4c< KA,4 f✓10vb Fc AN 2 1 b. Project Number 2b. Employee's Phone Number(including area code)and Email Address Z 10a6,4 1 c. Contractor or Subcontractor(Employer—not individual's name or 2c. Employee's Home Address& ip Code supervisor's name) 4 EOWDA 2d. Verifi ation of identification? Yes No ❑ 3a. How long on this 3b. Last date on this 3c.Number of hours 4a. Hourly Rate of Pay 4b.Fringe benefits? 4c. Frequency of job and average job before today? last day on this job? r�7( Pay: rJ weekly hours Medical Yes I No ❑ Weekly 02" worked? Pension Yes❑ No 5Z Biweekly❑Semi-monthly❑ 7PAvs Igo -^,t �- Other O 5. Yo r Job Classification(s)(list all and continue on a separate sheet if necessary): 4_Kctm 6. Your Duties: SAw cv-r, �PaM s-7, nRs�uF� 7. Tools or Eq ipment Used: NNopy l k1kr_V h+►MttiG(< Y N Y N 8.Are you an apprentice or trainee? ❑ FO 10.Are you paid at least time and'/Z(1.5x regular hourly rate)for all hours worked in ❑ excess of 40 in a week? 8a.Have you provided a copy of your ❑ 01 apprenticeship certificate? EVA 9.Are you paid for all hours worked? d ❑ 11. Have you ever been threatened or coerced into giving up any part of your pay? ❑ 12a. Employee Si nature 12b. Date 13. Duties Observed by the Interviewer(Please be specific): S2+*Y w*TErt t=c� ru rNt N 4TC-k /S urF/1,L0 >ET r-M,­u FOK p,eroE 411el"41 H 14. Remarks 15a. Interviewer Name(please print) 15b. Si nat re f Interviewer 15c. Date of Interview A—t,-TK,C.j gea -ZCZ< (•� Payroll Examination 16. Remarks 17a. Signature of Payroll Examiner 17b. Date Previous editions are obsolete Form HUD-11(03/2025) Record of U.S. Department of Housing and Urban Development OMB Approval No. 2501-0009 Office of Davis-Bacon and Labor Standards (exp. 03/31/2028) Em to ee Interview 18.Additional Remarks Previous editions are obsolete Form HUD-11(0312025) Record of U.S. Department of Housing and Urban Development OMB Approval No. 2501-0009 Office of Davis-Bacon and Labor Standards (exp. 03/31/2028) Employee Interview Public reporting burden for this collection of information is estimated to average 15 minutes per response,including the time for reviewing instructions,searching existing data sources, gathering and maintaining the data needed,and completing and reviewing the collection of information.This agency may not collect this information,and you are not required to complete this form,unless it displays a currently valid OMB control number. The information is collected to ensure compliance with the Federal labor standards by recording interviews with construction workers.The information collected will assist HUD in the conduct of compliance monitoring,the information will be used to test the veracity of certified payroll reports submitted by the employer.Sensitive Information.The information collected on this form is considered sensitive and is protected by the Privacy Act.The Privacy Act requires that these records be maintained with appropriate administrative,technical,and physical safeguards to ensure their security and confidentiality.In addition,these records should be protected against any anticipated threats or hazards to their security or integrity that could result in substantial harm,embarrassment,inconvenience,or unfairness to any individual on whom the information is maintained.The information collected herein is voluntary,and any information provided shall be kept confidential. Note: Please ensure responses are legible and eas to read. 1a. Project Name 2a. Employee's Full Name SG-8 Z I L6"S#C�t et Vc 4)A S► w JC,(C /MVRCV6M 94A, V c- vE L 1b. Project Number 2b. Employee's Phone Number(including area code)and Email Address cD86 Ak, .- 2•i—6Q 12 etPAl., -z/oo8 1 c. Contractor or Subcontractor(Employer—not individual's name or 2c. Employee's Home Address&Zip Code supervisor's name) LEoulD4 6"'Pe" 2d. Verification of identification? YesF1 No ❑ 3a. How long on this 31b. Last date on this 3c.Number of hours 4a. Hourly Rate of Pay 4b. Fringe benefits? 4c. Frequency of job and average job before today? last day on this job? Pay: weekly hours Medical Yes No ❑ Weekly I� worked? El Pension Yes❑ No Biweekly Semi-monthly❑ JZPAV� r�rs WK -7 Z� Other El 5. Your Job Classification(s)(list all and continue on a separate sheet if necessary): (_Af occc 6. Your Duties: I,—( -I I A/C lAiOHAe 7. Too s or Equipment Used: WALK 95HrN0 COAICte-r6144Pl44CT SAW Y N Y N 8.Are you an apprentice or trainee? ❑ � 10.Are you paid at least time and'/2(1.5x regular hourly rate)for all hours worked in ❑ excess of 40 in a week? 8a. Have you provided a copy of your ❑ ❑ apprenticeship certificate? 9.Are you paid for all hours worked? © ❑ 11. Have you ever been threatened or coerced into giving up any part of your pay? ❑ 12 E ployee Signature 12b. Date �--- -7-9 13. Duties Observed by the ewer(Please be speck): OBS EXj&D vS/AfG (W'41 IC,QCHi C, A;o$14C-7 S'qw 14, Remarks 15a. Interviewer Name(please print) 15b. Sign tur of I terviewer 15c.TDate of Interview M�+-r1�+ 2ecro ?-9-Z a� Payroll Examination 16. Remarks 17a. Signature of Payroll Examiner 17b. Date Previous editions are obsolete Form HUD-11(03/2025) Record Of U.S. Department of Housing and Urban Development OMB Approval No. 2501-0009 Office of Davis-Bacon and Labor Standards (exp. 03/31/2028) Employee Interview 18.Additional Remarks Previous editions are obsolete Form HUD-11(03/2025) Record of U.S. Department of Housing and Urban Development OMB Approval No. 2501-0009 Employee Interview Office of Davis-Bacon and Labor Standards (exp. 03/31/2028) Public reporting burden for this collection of information is estimated to average 15 minutes per response,including the time for reviewing instructions,searching existing data sources, gathering and maintaining the data needed,and completing and reviewing the collection of information.This agency may not collect this information,and you are not required to complete this form,unless it displays a currently valid OMB control number. The information is collected to ensure compliance with the Federal labor standards by recording interviews with construction workers.The information collected will assist HUD in the conduct of compliance monitoring:the information will be used to test the veracity of certified payroll reports submitted by the employer.Sensitive Information.The information collected on this form is considered sensitive and is protected by the Privacy Act.The Privacy Act requires that these records be maintained with appropriate administrative,technical,and physical safeguards to ensure their security and confidentiality.In addition,these records should be protected against any anticipated threats or hazards to their security or integrity that could result in substantial harm,embarrassment,inconvenience.or unfaimess to any individual on whom the information is maintained.The information collected herein is voluntary,and any infortnation provided shall be kept confidential. Note: Please ensure responses are legible and easy to read. 1 a. Project Name 2a. Employee's Full Name CC)F,C.1Jg SZ/ r!,q.Arff cE D2. 4(-)14 S7GCw.f�K MyN 0 . rkItAJ 4ND 1 b. Project Number 2b. Employee's Phone Number(including area code)and Email Address Zioa8 / 1 c. Contractor or Subcontractor(Employer-not individual's name or 2c. Employee's Home Address&ZiI5 Code supervisor's name) bFONIDA � 2d. Verl cation o identification? Yes F71 No ❑ 3a. How long on this 3b. Last date on this 3c.Number of hours 4a. Hourly Rate of Pay 4b. Fringe benefits? 4c. Frequency of job and average job before today? last day on this job? / Pay weekly hours T-- r Medical Yes No ❑ Weekly worked? (�-/(,-Z 8 J / Biweekly❑ Pension Yes❑ No a y Semi-monthly❑ 7 Df}i S Grj Other❑ 5. Your Job Classifi tion(s)(list all and continue on a separate sheet if necessary): �C,1rv�^4N /fV 4 cfcl"IF OrF2 4 ZC C 6. Your Duties: I-eAb TNCv,,OkC CREW LS0PF1(v-AX IOPF0rtE ko`I IPA'0V AP/Z 7. Tools or Equipment Used: �AMt'^Er,l Z�;UCC, 5(�rJA4C , �CLL EL r CxCugT�rt�772RcYc< S Y N Y N 8.Are you an apprentice or trainee? ❑ 10.Are you paid at least time and Yz(1.5x regular hourly rate)for all hours worked in ❑ excess of 40 in a week? 8a. Have you provided a copy of your ❑ apprenticeship certificate? 9.Are you paid for all hours worked? ❑ 11. Have you ever been threatened or coerced into giving up any part of your pay? ❑ 12a.Employee Signature 12b. Date G / 2S 1 ties Observed by the Interviewer(Please be specific): (�PF.4 4TC IVW [XCA,,R-rc R ro,c,�w/SePF¢toscat - G mac- p,rec*w (rc w 14. Remarks 15a. Interviewer Name(please print) 715b. S atur f-Interviewer 15c. Date of Interview Payroll Examination 16. Remarks 17a. Signature of Payroll Examiner 17b. Date Previous editions are obsolete Form HUD.11(0312025) Record of U.S. Department of Housing and Urban Development OMB Approval No. 2501-0009 Employee Interview Office of Davis-Bacon and Labor Standards (exp. 03/31/2028) 18.Additional Remarks Previous editions are obsolete Form HUD-11(03/2026) Record of U.S. Department of Housing and Urban Development OMB Approval No 2501-0009 Employee Interview Office of Davis-Bacon and Labor Standards (exp. 03/31/2028) Public reporting burden for this collection of information is estimated to average 15 minutes per response.including the time for reviewing instructions,searching existing data sources. gathering and maintaining the data needed,and completing and reviewing the collection of information This agency may not collect this information.and you are not required to complete this form.unless it displays a currently valid OMB control number The information is collected to ensure compliance with the Federal labor standards by recording interviews with construction workers The information collected will assist HUD in the conduct of compliance monitoring:the information will be used to test the veracity of certified payroll reports submitted by the employer.Sensitive Information.The information collected on this form is considered sensitive and is protected by the Privacy Act The Privacy Act requires that these records be maintained with appropriate administrative,technical,and physical safeguards to ensure their security and confidentiality.In addition,these records should be protected against any anticipated threats or hazards to their security or integrity that could result in substantial harts.embarrassment,inconvenience,or unfaimess to any individual on whom the information is maintained The information collected herein is voluntary.and any information provided shall be kept confidential. Note: Please ensure responses are legible and easy to read. la. Project Name 2a. Em loyee s Full Name S&-$ZI CM�SgocE pNPE Pit Si0.6w4ulr /e*PtP✓C T �O LoPC2 1 b. Project Number 2b. Emplloye�e'ss Phone Number(including area code)and Email Address C0dG Avo. - l•LE. ply•It GIP//p- 2 /00 1c. Contractor or Subcontractor(Employer—not individual's name or 2c. Employee's Home Address 8 Zip Code supervisor's name) 2d. Ve cation of identification? Yes No ❑ 3a.How long on this 3b. Last date on this 3c-Number of hours 4a. Hourly Rate of Pay 4b. Fringe benefits? 4c. Frequency of job and average job before today? last day on this job? Pay weekly hours Medical Yes No ❑ Weekly worked? Pension Yes No ❑ ® Biweekly❑ 9 L 5 Semi-monthly❑ Other❑ 5. Your Job Classification(s)(list all and continue on a separate sheet if necessary): Tee P P_1-16P 6. Your Duties: Oe%W--- 7 Tools or Equipment sed: bump TTQcc,C Y N Y N 8.Are you an apprentice or trainee? ❑ 10.Are you paid at least time and%(1.5x regular hourly rate)for all hours worked in d ❑ excess of 40 in a week? 8a. Have you provided a copy of your ❑ ❑ apprenticeship certificate? 9.Are y u paid for all hours worked? � El11. Have you ever been threatened or coerced into giving up any part of your pay? ❑ 0 12a. Employee Signature 12b. Date 7-9- 75' — 13. Duties Observed by the Interviewer(Please be specific): 1)q.vulG `--,* 74uCK,, pQOPPIN(o Cps; CC,901 04 M/FTE,9f,44 14. Remarks 15a. Interviewer Name(please print) 15b. Signature of Interviewer 15c. Date of Interview M�HEw 12 7_9'?S Pa roll Examination 16 Remarks 17a. Signature of Payroll Examiner 17b. Date Previous editions are obsolete Form HUD 11(03/2025) Record of U.S. Department of Housing and Urban Development OMB Approval No. 2501-0009 Employee Interview Office of Davis-Bacon and Labor Standards (exp. 03/31/2028) � _ 18.Additional Remarks Previous editions are obsolete Form HUD-11(03/2025)