Form LS680 "Mandatory Overtime for Nurses Complaint Form" - New York

What Is Form LS680?

This is a legal form that was released by the New York State Department of Labor - a government authority operating within New York. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2017;
  • The latest edition provided by the New York State Department of Labor;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form LS680 by clicking the link below or browse more documents and templates provided by the New York State Department of Labor.

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Download Form LS680 "Mandatory Overtime for Nurses Complaint Form" - New York

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Division of Labor Standards
Case No. (for state use only):
State Office Campus
Building 12, Room 185
Albany, NY 12240
(888) 4-NYSDOL or (518) 457-9000
(518) 457-8452 (fax)
labor.sm.lsclaim.intake@labor.ny.gov
Mandatory Overtime for Nurses Complaint Form
Instructions:
 Please type or print legibly.
 Please attach documentation that supports your claim or provides a more detailed answer for any of the questions.
 Mail, fax or e-mail your form to the address above.
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.
XXX – XX -
1. Name: (Last)
(First)
(Initial) 3. Social Security Number:
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:
Other – explain:
Hospital
Nursing home
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.
13. Did you volunteer to work this overtime?
Yes
No
If “Yes,” please explain (attach additional sheets if necessary):
LS 680 (04/17)
Page 1 of 2
Division of Labor Standards
Case No. (for state use only):
State Office Campus
Building 12, Room 185
Albany, NY 12240
(888) 4-NYSDOL or (518) 457-9000
(518) 457-8452 (fax)
labor.sm.lsclaim.intake@labor.ny.gov
Mandatory Overtime for Nurses Complaint Form
Instructions:
 Please type or print legibly.
 Please attach documentation that supports your claim or provides a more detailed answer for any of the questions.
 Mail, fax or e-mail your form to the address above.
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.
XXX – XX -
1. Name: (Last)
(First)
(Initial) 3. Social Security Number:
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:
Other – explain:
Hospital
Nursing home
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.
13. Did you volunteer to work this overtime?
Yes
No
If “Yes,” please explain (attach additional sheets if necessary):
LS 680 (04/17)
Page 1 of 2
14. Did you previously agree to work on-call shifts?
Yes
No
If “Yes,” explain:
15. Did your employer explain the reason for the mandatory overtime?
Yes
No
If “Yes,” what reason was given?
16. Was the overtime required due to unforeseeable emergency circumstances?
Yes
No
Not Sure
If “Yes,” what were the circumstances?
17. Do you believe the overtime was required due to vacancies resulting from chronic
Yes
No
Not Sure
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
Yes
No
Not Sure
or disaster or other catastrophic event? If yes, please explain:
19. Was the overtime required because your employer determined there was a patient care
Yes
No
Not Sure
emergency? If “Yes,” please explain:
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?
Yes
No
Not Sure
b. Did your employer contact employees who made themselves available to work
extra time?
Yes
No
Not Sure
c. Did your employer contact per diem staff?
Yes
No
Not Sure
d. Did your employer contact a temporary agency?
Yes
No
Not Sure
21. Are you represented by a union?
Yes
No
If “Yes,” provide local name, number and address:
22. Please use the space below or 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 that the New York State Department of Labor, Division of Labor Standards, investigate the claim indicated by the information
supplied in this complaint and advise me of the results of the investigation.
Signature:
Date:
LS 680 (04/17)
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