If you're a California small business owner, you may be wondering whether or not you need to file Form LS 680. This form is used to report the sale of certain items by retailers, and it's important to know whether or not your business needs to submit it. In this article, we'll take a closer look at Form LS 680 and explain who needs to file it. We'll also provide some tips on how to complete the form correctly. Let's get started!
| Question | Answer |
|---|---|
| Form Name | Form Ls 680 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | LS680 mandatory overtime for nurses complaint form nys |
New York State Department of Labor
Division of Labor Standards
Mandatory Overtime for Nurses Complaint Form
Instructions:
•Please type or print legibly.
•You may attach any documentation that supports your claim and/or provides a more detailed answer for any of the questions.
•Mail, fax or
NYS Department of Labor |
Case No. (for state use only): |
Division of Labor Standards |
Telephone No.: (518) |
State Campus, Bldg 12, Rm. 185B |
www. http://www.labor.state.ny.us/ |
Albany, NY 12240 |
Email: labor.sm.lsclaim.intake@labor.state.ny.us |
Acceptance of this claim by the Department does not imply that the employer is in violation of any law or regulation on mandatory overtime restrictions for healthcare facilities.
1. |
Name: (Last) |
(First) |
|
(Initial) |
3. |
Social Security Number: |
XXX – XX - |
|
|
2. |
Street Address: |
|
|
|
4. Telephone number with area code: |
- |
- |
||
|
City: |
State: |
|
Zip Code |
5. |
Alternate telephone number: |
- |
|
- |
6. |
Are you an hourly employee: |
Yes |
No |
Occupation/Job title: |
|
|
|
||
7.Name of employer:
8.Employer street address:
City |
State |
Zip Code |
Telephone number: |
- |
- |
9. Name of supervisor: |
|
|
Telephone number: |
- |
- |
10.Employer mailing address (if different from above):
11.Nature of employer’s business:
Hospital
Nursing home
Other – explain
Mandatory Overtime Information
12.For each incident for which you had to work mandatory overtime, provide the date, the hours you were originally scheduled to work, and the overtime hours you were required to work.
Date(s) |
|
|
|
Original Schedule |
|
|
Mandatory Overtime |
|||||
MM/DD/YYYY |
|
Start Time |
|
End Time |
|
Total Hrs. |
|
Start Time |
|
End Time |
|
Total Hrs. |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
LS 680 (10/09)
13.Did you volunteer to work this overtime?
If “Yes,” please explain (attach additional sheets if necessary):
14.Did you previously agree to work
15.Did your employer explain the reason for the mandatory overtime? If “Yes,” what reason was given?
16.Was the overtime required due to unforeseeable emergency circumstances? If “Yes,” what were the circumstances?
17.Do you believe the overtime was required due to vacancies resulting from chronic staffing shortages? If yes, please explain and attach any supporting documentation:
18.Was the overtime required due to any declared national, state, or municipal emergency or disaster or other catastrophic event? If yes, please explain:
19.Was the overtime required because your employer determined there was a patient care emergency? If “Yes,” please explain:
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
Not Sure
Not Sure
Not Sure
Not Sure
20.Depending on the reason for the mandatory overtime, your employer may have been required to exhaust reasonable efforts to obtain staffing. Please answer the following questions to the best of your knowledge:
a.Did your employer ask for volunteers to work overtime?
b.Did your employer contact employees who made themselves available to work extra time?
c.Did your employer contact per diem staff?
d.Did your employer contact a temporary agency?
21.Are you represented by a union?
If “Yes,” provide local name, number and address:
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Not Sure
Not Sure
Not Sure
Not Sure
22.Please use a separate sheet of paper to provide any additional information you may have regarding this complaint. Attach any documentation you may have that supports your complaint.
I request the New York State Department of Labor, Division of Labor Standards, to investigate the claim indicated by the information supplied in this complaint and advise me of the results of the investigation.
Signature |
|
Date |