Form Pusd A 36 5 16 PDF Details

Navigating the intricate process of employing minors requires a nuanced understanding of both federal and state regulations to ensure compliance and protect the rights of young workers. The Request for Work Permit and Statement of Intent to Employ Minor form, commonly referred to as the PUSD A 36 5 16 form, serves as a critical document within this framework, especially within the Poway Unified School District in California. This form not only formalizes the intent of employers to hire minors but also encompasses a comprehensive declaration from the employer, the minor’s parents or guardians, and school officials, thereby encapsulating all necessary approvals before the commencement of employment. It meticulously records details such as the minor’s personal and school information, the nature of the intended job, and the working hours, in addition to obtaining signatures that validate the agreement from all parties involved. Moreover, the form highlights pertinent state and federal regulations, offering a concise overview of the legal constraints surrounding minor employment, including work hours, permissible job types, and conditions under which work permits can be revoked, thereby emphasizing the balance between utilizing the workforce and safeguarding the education and welfare of minors.

QuestionAnswer
Form NameForm Pusd A 36 5 16
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesnonschoolday, 1995, sawmilling, forklifts

Form Preview Example

REQUEST FOR WORK PERMIT AND STATEMENT OF INTENT TO EMPLOY MINOR (B1-1)

THIS DOCUMENT IS NOT A WORK PERMIT

POWAY UNIFIED SCHOOL DISTRICT

13626 Twin Peaks Road, Poway, California 92064-3034

See Reverse Side for Pertinent State and Federal Regulations Note: No carbon required.

1. STATEMENT OF EMPLOYER – I intend to employ

 

MINOR'S NAME

 

 

 

 

 

 

 

 

 

HOME ADDRESS

 

 

 

 

 

 

 

 

 

CITY

 

 

 

 

ZIP CODE

 

TEL.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME OF BUSINESS

 

 

 

 

 

 

 

 

 

BUSINESS ADDRESS

 

 

 

 

 

 

 

CITY

 

 

 

 

ZIP CODE

 

BUS. TEL.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TYPE OF BUSINESS

 

 

 

 

 

KIND OF WORK MINOR WILL DO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE HIRED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME AND TITLE OF SUPERVISOR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does Student

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Work After

 

EMPLOYMENT – SEE REVERSE SIDE RE HOURS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TOTAL HOURS PER WEEK

 

 

 

WAGES PER HOUR

 

 

10 p.m.?

 

 

 

 

 

 

M

 

 

T

W

 

 

TH

 

F

SAT.

 

SUN.

 

 

 

 

 

 

 

 

TOTAL HOURS OF

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMPLOYMENT PER DAY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SEE REVERSE SIDE RE WAGES

 

■

■

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMPLOYER’S WORKER’S COMPENSATION CARRIER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SIGNATURE OF EMPLOYER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

x

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2. STATEMENT OF PARENT OR GUARDIAN REGARDING MINOR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME OF SCHOOL

 

 

 

 

 

 

 

 

 

 

SEX

 

 

 

SOCIAL SECURITY NUMBER

 

GRADE LEVEL

 

AGE

 

 

DATE OF BIRTH

BIRTHPLACE (State)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

-

 

 

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

THIS EMPLOYMENT MEETS MY APPROVAL

SIGNATURE AND RELATIONSHIP (Mother, Father, or Guardian)

 

 

 

 

 

 

 

 

 

DATE

 

 

 

 

 

 

 

 

YES

 

NO

x

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

■

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

■

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3. STATEMENT BY SCHOOL OFFICIAL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TYPE OF STUDENT

 

 

 

 

 

PROOF OF AGE

 

 

 

 

 

 

 

 

 

 

REMARKS

 

 

 

 

 

 

 

 

 

■ Regular

 

 

 

 

 

 

 

Birth Cert

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

■Work Exp. Ed.

(as verified by) _________________

Sch. Record

 

 

 

■ Vacation Employee

Other

 

 

 

■ Other ________________________

 

 

 

 

 

 

 

 

 

 

 

 

This is to certify that the above information agrees with the records

SIGNATURE OF SCHOOL OFFICIAL

 

DATE

 

 

 

of this school.

 

x

 

 

PUSD A-36/5.16 (Rev. 9/01)

 

Distribution: WHITE – Partners in Education

YELLOW – Employer PINK – School

REQUEST FOR WORK PERMIT AND STATEMENT OF INTENT TO EMPLOY MINOR (B1-1)

THIS DOCUMENT IS NOT A WORK PERMIT

POWAY UNIFIED SCHOOL DISTRICT

13626 Twin Peaks Road, Poway, California 92064-3034

See Reverse Side for Pertinent State and Federal Regulations Note: No carbon required.

1. STATEMENT OF EMPLOYER – I intend to employ

 

MINOR'S NAME

 

 

 

 

 

 

 

 

 

HOME ADDRESS

 

 

 

 

 

 

 

 

 

CITY

 

 

 

 

ZIP CODE

 

TEL.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME OF BUSINESS

 

 

 

 

 

 

 

 

 

BUSINESS ADDRESS

 

 

 

 

 

 

 

CITY

 

 

 

 

ZIP CODE

 

BUS. TEL.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TYPE OF BUSINESS

 

 

 

 

 

KIND OF WORK MINOR WILL DO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE HIRED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME AND TITLE OF SUPERVISOR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does Student

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Work After

 

EMPLOYMENT – SEE REVERSE SIDE RE HOURS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TOTAL HOURS PER WEEK

 

 

 

WAGES PER HOUR

 

 

10 p.m.?

 

 

 

 

 

 

M

 

 

T

W

 

 

TH

 

F

SAT.

 

SUN.

 

 

 

 

 

 

 

 

TOTAL HOURS OF

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMPLOYMENT PER DAY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SEE REVERSE SIDE RE WAGES

 

■

■

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMPLOYER’S WORKER’S COMPENSATION CARRIER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SIGNATURE OF EMPLOYER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

x

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2. STATEMENT OF PARENT OR GUARDIAN REGARDING MINOR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME OF SCHOOL

 

 

 

 

 

 

 

 

 

 

SEX

 

 

 

SOCIAL SECURITY NUMBER

 

GRADE LEVEL

 

AGE

 

 

DATE OF BIRTH

BIRTHPLACE (State)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

-

 

 

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

THIS EMPLOYMENT MEETS MY APPROVAL

SIGNATURE AND RELATIONSHIP (Mother, Father, or Guardian)

 

 

 

 

 

 

 

 

 

DATE

 

 

 

 

 

 

 

 

YES

 

NO

x

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

■

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

■

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3. STATEMENT BY SCHOOL OFFICIAL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TYPE OF STUDENT

 

 

 

 

 

PROOF OF AGE

 

 

 

 

 

 

 

 

 

 

REMARKS

 

 

 

 

 

 

 

 

 

■ Regular

 

 

 

 

 

 

 

Birth Cert

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

■Work Exp. Ed.

(as verified by) _________________

Sch. Record

 

 

■ Vacation Employee

Other

 

 

■ Other ________________________

 

 

 

 

 

 

 

 

 

This is to certify that the above information agrees with the records

SIGNATURE OF SCHOOL OFFICIAL

DATE

 

 

of this school.

 

x

 

PUSD A-36/5.16 (Rev. 9/01)

Distribution: WHITE – Partners in Education YELLOW – Employer PINK – School

Laws and Agencies Controlling Employment of Minors

Most California employers are governed not only by state child labor laws but by the child labor provisions of the federal Fair Labor Standards Act (FLSA). When federal and state laws both apply, the more restrictive law prevails.

FLSA sets basic minimum ages of 16 for general employment and 18 for occupations declared particularly hazardous for young workers. Persons younger than 16 are allowed to work only in limited, specified occupations which exclude baking. manufacturing, processing, construction, warehouse, and transportation occupations. (See U. S. Department of Labor (DOL) Child Labor Bulletins 101 and 102.)

California law also sets out minimum ages, as summarized below, and restricts or prohibits employment of specified age groups of minors in specified hazardous occupations. (See “California Child Labor Laws 1995-96,” a publication of the California Division of Labor Standards Enforcement.)

Information on federal labor laws is available from the DOL's Wage and Hour Division, Employment Standards Administration. Information on state child labor laws is available from the Division of Labor Standards Enforcement. Both the federal and state agencies have offices in several California cities.

Summary of Minors' Work Regulations

1.Federal and state law generally prohibit nonfarm employment of children younger than 14. Special rules apply to agricultural and domestic work and to the entertainment industry.

2.Children generally must attend school until age 18 unless they are 16 or older and have graduated from high school or received a state Certificate of Proficiency.

3.Employers of minors required to attend school must have a “Statement of Intent to Employ Minor and Request for Work Permit” (Form B I - I ) on file with the school district of attendance for each such minor and must themselves have on file for each minor a “Permit to Employ and Work” (Form B 1-4). Records are to be open at all times for inspection by school authorities and officers of the Division of Labor Standards Enforcement.

4.A work permit must be revoked whenever the issuing authority determines the employment is illegal or is impairing the health or education of the minor.

5.Labor laws applicable to adult employees are also generally applicable to minor employees, including workers’ compensation insurance requirements.

6.Child labor laws do not generally apply to minors who deliver newspapers or work at odd jobs, such as yard work and baby-sitting or in private homes where the minor is not regularly employed.

7.Hours of work: (When federal and state laws both apply, the more restrictive law prevails.)

Age

Federal Regulations

Age

State Law

12-13

Prohibits the nonfarm employment of minors under the age of 14.

12-13

Cannot work on schooldays. When school is not in session: daily maximum 8 hours, weekly maximum 40 hours.

14-15

When school is in session: daily maximum 3 hours. weekly maximum 18 hours, except 23 hours if

14-15

Same as federal regulations.

 

student is in Work Experience Education program. (Generally may not work

 

 

 

during school hours except in Work Experience Education program.) When school is not in session:

 

 

 

daily maximum 8 hours and weekly maximum 40 hours.

 

 

16-17 Same as for adult—state child labor standard prevails.

8. Spread of hours:

12-13 (See 1, above)

16-17 Four (4) hours per day on any schoolday. Eight (8) hours on any nonschoolday or on any day that precedes a non-schoolday. May be permitted to work 48 hours per week. Maximum hours vary per school district policy. Work Experience Education student may be permitted to work a maximum of 8 hours on a schoolday. High school graduates and state Certificate of Proficiency recipients are treated as adults.

12-13 Work must be performed between 7 a.m. and 7 p.m. except June I through Labor Day when the hour is extended until 9 p.m.

14-15

Work must be performed between 7 a.m. and 7 p.m. except June 1 through Labor Day when the hour is

14-15

Same as federal regulations.

 

extended until 9 p.m.

 

 

16-17 Same as for adult—state child labor standard prevails.

16-17 Work must be performed between 5 a.m. and 10 p.m. except that work may extend to one-half hour past midnight on nights preceding non-schooldays. Student in Work Experience Education program may be autho- rized to work until one-half hour past midnight on nights preceding schooldays.

9.A day of rest from work is required if the total hours worked per week exceed 30 or if more than 6 hours are worked on any one day during the week.

10.Prohibited hazardous occupations for minors under 18 by the federal and state law:

1.

Explosives

7. Power-driven hoists/forklifts

13.

Manufacturing brick, tile products

2.

Motor vehicle driving/outside helper

*8. Power-driven metal forming, punching, and shearing machines

*14.

Power saws and shears

3.

Coal mining

9. Other mining

15.

Wrecking, demolition

4.

Logging and sawmilling

*10. Power-driven meat slicing/processing machines and meat slaughtering

*16.

Roofing

*5.

Power-driven woodworking machines

11. Power baking machines

*17.

Excavation operation

6.

Radiation exposure

*12. Power-driven paper products/paper-baling machines

 

 

*See U.S. Department of Labor Bulletin 101, "Child Labor Requirements in Nonagricultural Occupations Under the Fair Labor Standards Act," for apprentice and student-learner exemptions.

Laws and Agencies Controlling Employment of Minors

Most California employers are governed not only by state child labor laws but by the child labor provisions of the federal Fair Labor Standards Act (FLSA). When federal and state laws both apply, the more restrictive law prevails.

FLSA sets basic minimum ages of 16 for general employment and 18 for occupations declared particularly hazardous for young workers. Persons younger than 16 are allowed to work only in limited, specified occupations which exclude baking. manufacturing, processing, construction, warehouse, and transportation occupations. (See U. S. Department of Labor (DOL) Child Labor Bulletins 101 and 102.)

California law also sets out minimum ages, as summarized below, and restricts or prohibits employment of specified age groups of minors in specified hazardous occupations. (See “California Child Labor Laws 1995-96,” a publication of the California Division of Labor Standards Enforcement.)

Information on federal labor laws is available from the DOL's Wage and Hour Division, Employment Standards Administration. Information on state child labor laws is available from the Division of Labor Standards Enforcement. Both the federal and state agencies have offices in several California cities.

Summary of Minors' Work Regulations

1.Federal and state law generally prohibit nonfarm employment of children younger than 14. Special rules apply to agricultural and domestic work and to the entertainment industry.

2.Children generally must attend school until age 18 unless they are 16 or older and have graduated from high school or received a state Certificate of Proficiency.

3.Employers of minors required to attend school must have a “Statement of Intent to Employ Minor and Request for Work Permit” (Form B I - I ) on file with the school district of attendance for each such minor and must themselves have on file for each minor a “Permit to Employ and Work” (Form B 1-4). Records are to be open at all times for inspection by school authorities and officers of the Division of Labor Standards Enforcement.

4.A work permit must be revoked whenever the issuing authority determines the employment is illegal or is impairing the health or education of the minor.

5.Labor laws applicable to adult employees are also generally applicable to minor employees, including workers’ compensation insurance requirements.

6.Child labor laws do not generally apply to minors who deliver newspapers or work at odd jobs, such as yard work and baby-sitting or in private homes where the minor is not regularly employed.

7.Hours of work: (When federal and state laws both apply, the more restrictive law prevails.)

Age

Federal Regulations

Age

State Law

12-13

Prohibits the nonfarm employment of minors under the age of 14.

12-13

Cannot work on schooldays. When school is not in session: daily maximum 8 hours, weekly maximum 40 hours.

14-15

When school is in session: daily maximum 3 hours. weekly maximum 18 hours, except 23 hours if

14-15

Same as federal regulations.

 

student is in Work Experience Education program. (Generally may not work

 

 

 

during school hours except in Work Experience Education program.) When school is not in session:

 

 

 

daily maximum 8 hours and weekly maximum 40 hours.

 

 

16-17 Same as for adult—state child labor standard prevails.

8. Spread of hours:

12-13 (See 1, above)

16-17 Four (4) hours per day on any schoolday. Eight (8) hours on any nonschoolday or on any day that precedes a non-schoolday. May be permitted to work 48 hours per week. Maximum hours vary per school district policy. Work Experience Education student may be permitted to work a maximum of 8 hours on a schoolday. High school graduates and state Certificate of Proficiency recipients are treated as adults.

12-13 Work must be performed between 7 a.m. and 7 p.m. except June I through Labor Day when the hour is extended until 9 p.m.

14-15

Work must be performed between 7 a.m. and 7 p.m. except June 1 through Labor Day when the hour is

14-15

Same as federal regulations.

 

extended until 9 p.m.

 

 

16-17 Same as for adult—state child labor standard prevails.

16-17 Work must be performed between 5 a.m. and 10 p.m. except that work may extend to one-half hour past midnight on nights preceding non-schooldays. Student in Work Experience Education program may be autho- rized to work until one-half hour past midnight on nights preceding schooldays.

9.A day of rest from work is required if the total hours worked per week exceed 30 or if more than 6 hours are worked on any one day during the week.

10.Prohibited hazardous occupations for minors under 18 by the federal and state law:

1.

Explosives

7. Power-driven hoists/forklifts

13.

Manufacturing brick, tile products

2.

Motor vehicle driving/outside helper

*8. Power-driven metal forming, punching, and shearing machines

*14.

Power saws and shears

3.

Coal mining

9. Other mining

15.

Wrecking, demolition

4.

Logging and sawmilling

*10. Power-driven meat slicing/processing machines and meat slaughtering

*16.

Roofing

*5.

Power-driven woodworking machines

11. Power baking machines

*17.

Excavation operation

6.

Radiation exposure

*12. Power-driven paper products/paper-baling machines

 

 

*See U.S. Department of Labor Bulletin 101, "Child Labor Requirements in Nonagricultural Occupations Under the Fair Labor Standards Act," for apprentice and student-learner exemptions.

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