LABOR STANDARDS INVESTIGATION SUMMARY SHEET

OMB No.: 9000-0089
Expires:    03/31/93

CONTRACT NUMBER

Public reporting burden for this collection of information is estimated to average 15 mins. 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.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the FAR Secretariat (VRS), Office of Federal Acquisition Policy, GSA, Washington, DC 20405; and to the Office of Management and Budget, Paperwork Reduction Project (9000-0089), Washington, DC 20503.

REPORTING OFFICE

CONTRACT AMOUNT

DATE OF CONTRACT

TYPE OF CONTRACT

FIXED PRICE                         CPFF                        OTHER (Specify)

CONTRACTOR'S NAME AND ADDRESS (Include ZIP Code)

EMPLOYER'S NAME AND ADDRESS (Include ZIP Code)
(If other than prime contractor)

PROJECT AND LOCATION

DESCRIPTION OF WORK

BASIS FOR INVESTIGATION

WAGE DETERMINATION NUMBER

WAGE DETERMINATION DATE

NATURE AND EXTENT OF VIOLATION

NO. EMPLOYEES INVOLVED

ARE VIOLATIONS CONSIDERED WILLFUL?

YES             NO

COPELAND ACT VIOLATIONS

YES                             NO

DAVIS-BACON ACT UNDERPAYMENTS

$

CWHSSA* UNDERPAYMENTS

$

CWHSSA* LAW VIOLATIONS

$

CORRECTIVE ACTIONS TAKEN

RESTITUTION MADE

YES            NO

AMOUNT OF RESTITUTION

$

CONTRACTORS PAYMENT WITHHELD

YES                                NO

WITHHELD FOR DAVIS-BACON VIOLATIONS

$

WITHHELD FOR CWHSSA* UNDERPAYMENTS

$

WITHHELD FOR CWHSSA* VIOLATIONS

$

REMARKS

PREPARED BY

DATE

TITLE

SIGNATURE

* Contract Work Hours and Safety Standards Act

AUTHORIZED FOR LOCAL REPRODUCTION
Previous edition is usable

STANDARD FORM 1446 (REV. 12-90)
Prescribed by GSA-FAR (48 CFR) 53.222(h)