Housing Occupancy Certificate — Migrant
and Seasonal Agricultural Worker
U.S. Department of Labor
Wage and Hour Division
OMB Number: 1235-0006
Expiration Date: 08-31-2020
A. IDENTIFYING INFORMATION
1. Location of Housing Inspected:
Description of Housing Units and Number of Units:
Name and Address of Owner of Housing Units:
Expected Dates of Occupancy
Date of Inspection:
Date Certificate Expires:
2a. 3a. Name and Address of Individual(s) in Charge:
4a. Name and Address of Farm Labor Contractor, if Any: 5. Date Inspection was Requested:
CERTIFICATION: For Completion By Agency Personnel Conducting Housing Inspection
The housing identified above has been inspected by the undersigned and found to
meet the substantive safety and health standards prescribed in one of the following
Department of Labor regulations.
29 C.F.R. § 1910.142 Occupational Safety and Health Administration Regulations
20 C.F.R. Part 654 Emplo yment and Training Administration Regulations
The definition of substantive safety and health standards is given in 29 C.F.R. § 500.133.
(If none, write “None ”):
District Office Address:
(Signature and Title of Person Issuing Certificate) (Date Issued)
A copy of this certificate must be posted at the site of the housing identified above. This certificate is valid for one year from the date
of issuance. If after one year from the date of this certificate the property identified above is to be utilized to house migrant workers, a new certificate must
The original of this certificate must be kept as a record for three years from the date of issuance.
This inspection certificate does not relieve any person from compliance with any applicable State, county or local ordinance. Receipt and posting of this
certificate of occupancy does not relieve the persons who own or control this facility or property from the responsibility of ensuring that such facility or
property meets the applicable State and Federal safety and health standards. Once such facility or property is occupied, such person shall supervise
and continually maintain such facility or property to ensure that it remains in compliance with the applicable safety and health standards.
Public Burden Statement
valid OMB control number. Public reporting burden for this collection of information is estimated to average 4 minutes per response, including time
for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, completing and reviewing the collection of informa-
tion, and maintaining the records. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions
for reducing this burden, to the U.S. Department of Labor, Administrator, Wage and Hour Division, Room S-3502, 200 Constitution Avenue, N.W.,
Washington, D.C. 20210.
DO NOT SEND THE COMPLETED FORM TO THIS OFFICE.
Rev. July 2011
According to the Paperwork Reduction Act of 1995, no person is required to respond to this collection of information unless it displays a currently
Pursuant to 29 C.F.R. § 500.135, prior to occupancy it is mandatory for any person or organization which owns or controls a facility or real property
to be used for housing a migrant agricultural worker to obtain certification from a State or local health authority or other appropriate agency, including
a federal agency, that the facility or real property meets applicable safety and health standards. A copy of the certification must be posted at the
housing site prior to occupancy.