+---------------------------+---------------------+--------------------+
| **Record of**             | **U.S. Department   | OMB Approval No.   |
|                           | of Housing**        | 2501-0009          |
| **Employee Interview**    |                     |                    |
|                           | **and Urban         | (exp. 10/31/2010)  |
|                           | Development**       |                    |
|                           |                     |                    |
|                           | **Office of Labor   |                    |
|                           | Relations**         |                    |
+---------------------------+---------------------+--------------------+

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]{.underline}**. 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**.

<table style="width:100%;">
<colgroup>
<col style="width: 14%" />
<col style="width: 10%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 6%" />
<col style="width: 0%" />
<col style="width: 16%" />
<col style="width: 7%" />
<col style="width: 2%" />
<col style="width: 5%" />
<col style="width: 7%" />
<col style="width: 3%" />
<col style="width: 4%" />
<col style="width: 1%" />
<col style="width: 4%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="7"><p>1a. Project Name</p>
<p>     </p></td>
<td colspan="9"><p>2a. Employee Name</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="7"><p>1b. Project Number</p>
<p>     </p></td>
<td colspan="9"><p>2b. Employee Phone Number (including area code)</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="7" rowspan="2"><p>1c. Contractor or Subcontractor
(Employer)</p>
<p>     </p></td>
<td colspan="9"><p>2c. Employee Home Address &amp; Zip Code</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="9"><p>2d. Verification of identification?</p>
<p>Yes No </p></td>
</tr>
<tr class="odd">
<td rowspan="4"><p>3a. How long on this job?</p>
<p>     </p></td>
<td colspan="2" rowspan="4"><p>3b. Last date on this job before
today?</p>
<p>     </p></td>
<td colspan="3" rowspan="4"><p>3c. No. of hours last day on this
job?</p>
<p>     </p></td>
<td colspan="2" rowspan="4"><p>4a. Hourly rate of pay?</p>
<p>     </p></td>
<td colspan="4">4b. Fringe Benefits?</td>
<td colspan="4">4c. Pay stub?</td>
</tr>
<tr class="even">
<td>Vacation</td>
<td colspan="2">Yes </td>
<td>No </td>
<td colspan="2">Yes </td>
<td colspan="2">No </td>
</tr>
<tr class="odd">
<td>Medical</td>
<td colspan="2">Yes </td>
<td>No </td>
<td colspan="4" rowspan="2"></td>
</tr>
<tr class="even">
<td>Pension</td>
<td colspan="2">Yes </td>
<td>No </td>
</tr>
<tr class="odd">
<td colspan="16"><p>5. Your job classification(s) (list all) ---
continue on a separate sheet if necessary</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="16"><p>6. Your duties</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="16"><p>7. Tools or equipment used</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td><strong>Y</strong></td>
<td><strong>N</strong></td>
<td colspan="9"></td>
<td colspan="2"><strong>Y</strong></td>
<td><strong>N</strong></td>
</tr>
<tr class="odd">
<td colspan="2">8. Are you an apprentice or trainee?</td>
<td></td>
<td></td>
<td colspan="9">10. Are you paid at least time and ½ for all hours
worked in excess of 40 in a week?</td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2">9. Are you paid for all hours worked?</td>
<td></td>
<td></td>
<td colspan="9">11. Have you ever been threatened or coerced into giving
up any part of your pay?</td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="7"><p>12a. Employee Signature</p>
<p>     </p></td>
<td colspan="9"><p>12b. Date</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="16"><p>13. Duties observed by the Interviewer (Please be
specific.)</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="16"><p>14. Remarks</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="5"><p>15a. Interviewer name (please print)</p>
<p>     </p></td>
<td colspan="5"><p>15b. Signature of Interviewer</p>
<p>     </p></td>
<td colspan="6"><p>15c. Date of interview</p>
<p>     </p></td>
</tr>
</tbody>
</table>

**Payroll Examination**

+-----------------------------------+----------------------------------+
| 16\. Remarks                      |                                  |
|                                   |                                  |
|                                   |                                  |
+-----------------------------------+----------------------------------+
| 17a. **Signature of Payroll       | 17b. **Date**                    |
| Examiner**                        |                                  |
|                                   | **     **                        |
|                                   |                                  |
+-----------------------------------+----------------------------------+
| **Previous editions are           | **Form HUD-11 (08/2004)**        |
| obsolete**                        |                                  |
+-----------------------------------+----------------------------------+