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戏藽肚Date Issued: Name of Licensee/Vendor: Licensee/Vendor #: Region: Name of Factory: Factory #: Physical Address: Mailing Address: Telephone #: Fax #: Name of Contact: Facility Name: Physical Address: Mailing Address: Telephone #: Fax #: (Please review information above, make changes on form if necessary.)FACTORY:Ownership Type of Factory:Joint Venture _ Partnership _ Corporation _ Privately Owned _Foreign Investment _ Other _Name of Broker/Agent (if applicable): Mailing Address: Telephone #: Fax #: FACILITY (Note: Complete a questionnaire for each facility location)Ownership Type of Facility:Joint Venture _ Partnership _ Corporation _ Privately Owned _Foreign Investment _ Other _Year Facility Established: Name of Plant Manager: Telephone #: Fax #: Articles Produced: Total Employees at this Facility: Contract: Local: If contract workers employed, length of contract: Street Address of Dormitories (if applicable): SUBCONTRACTING FACILITIES OR SISTER COMPANIESName(s)_Location(s)_Operations performed_NUMBER OF MACHINES Specify the following:Number of EstimatedEmployees onMonthly Machine TypeNumberMachineProductionCutting Machines_Cutting Tables_Knitting Machines_Sewing Machines_Making Machines_Looping Machines_Processing Machines:Permapressing machines_Dying machines_Stone washing machines_Other_Weaving Machines_Yarn making Machines_COMPLETED BY:Name: Title: Signature: Date: 1.Are all employees voluntarily working in this facility?Yes o No oa.What procedures ensure/monitor that all employees are working voluntarily? 2. Are there any workers in this facility that are prisoners, have been assigned by the military, or any other branch of government?Yes o No o3.Do employees have freedom of movement that is not unnecessarily impeded? Yes o No oa.If no, explain: 4.Are employees free to leave when their work shift ends?Yes o No oa.If no, explain: 5.Are guards posted only for normal security reasons?Yes o No oa.If so, what are their basic duties? 6. Are doors and gates on the factory premises locked only for normal business security purposes?Yes o No oa.If no, explain: 7. What is the age of the youngest worker in this facility? a. What is the minimum age allowed by law? _b. Do you have a minimum age policy different from local law? Yes o No oIf yes, explain: c. Do workers execute a statement that they are at or above the minimum age? Yes o No oIf yes, is the statement filed in the employees personnel files? 8.Are there any work experience or apprentice programs for school age children?Yes o No oa.If yes, explain: 9.Are there restrictions for workers under 18?Yes o No oa.If yes, explain: 10.What proof of age documents are obtained from prospective employees? 11. What procedures does this facility have in place to verify the authenticity of age documentation? 12.How are employees recruited (i.e., newspaper advertisement, agent, contract)? 13.How does management handle misconduct or poor performance on the part of an employee? a. Does this management of misconduct or poor performance include fines? Yes o No oIf yes, explain factory policy. Include examples: 14.Do you restrict employment by age, race, ethnic group, religion, gender, sexual orientation, political affiliation, and/or national origin?Yes o No oa.If yes, explain: 15.What is the lowest wage paid by this facility for trained (i.e., production) employees? For untrained (i.e., janitors, trainees) employees? 16.How are employees paid?Cash o Check o Auto Pay o Other o17.How is the pay rate calculated?Per Hour o Piece Rate o Per Day o Other oa.If other, explain: 18. If employees are paid on a piece rate basis, what system does the facility use in order to track the number of pieces worked on each day by individual employees? 19.Is work time documented by a time card?Yes o No oa.If no, explain system: 20.How often are employees paid?Hourly o Weekly o Monthly o Other o21. Does the factory provide all employees a pay record or stub which details the current periods wage calculation? Yes o No oa. If no, explain: 22.Are there any deductions from employees wages?Yes o No oa.What charges are deducted from your employees pay? b.How is this documented? 23.Does any employee owe the factory money?Yes o No oa.If yes, explain: 24.What allowances and benefits are provided to employees in this facility? Please circle the following that apply: Housing, meals, transportation, and other allowances; health care; child care; sick leave; emergency leave; pregnancy and menstrual leave; vacation; religious and holiday leave; and contributions for social security, life, health, workers compensation and other insurance coverage.If food is provide, how many meals/day? _ Free o Subsidized o ; Other benefits _a. What benefits are required to be given to factory workers per local law? : 25.Are benefits and/or allowances included in calculating the minimum wage?Yes o No oa.If yes, explain: 26.Are there any incentive plans offered (e.g., bonuses)?Yes o No oa.If yes, explain: 27.Are workers paid any special wages, e.g., for probation or training?Yes o No oa.If yes, explain: 28. What is the facility policy on maximum consecutive days of work? a. How often in a 3 month period is that maximum exceeded? _29.What are the standard operating hours of this facility? From _a.m. to _ p.m.30.How many work shifts do you run in your facility? a.How many hours per work shift? 31.Do you pay for overtime?Yes o No oa. What is the minimum wage for overtime in the local law? _32.How are overtime wages calculated (e.g., weekdays 1.5x; holiday 2x, etc.)? 33.What is the average number of overtime hours worked per worker each week? 34.What is the maximum number of work hours per day at regular pay? 35.What is the maximum number of hours employees are asked to work in a given week? _36. Does the factory obtain waivers from governing authorities in the event that the number of planned work hours for a given week exceed the maximum as per local and national law? Yes o No oa.If no, explain: 37.Do employees have time each day for a meal?Yes o No o38.Do employees have time each day for breaks?Yes o No oa.If yes, how many and what is the duration of each break? 39.Do employees take work home?Yes o No oa. If yes, how are wages for this work determined? b. What type of work? _40.Are first aid supplies available in this facility?Yes o No o41.Are there any medically trained personnel on site?Yes o No o42.Are safety education/training programs offered (i.e., first aid, etc.)?Yes o No oa.If so, what? 43.Do you have fire extinguishers and/or sprinkler systems in this facility?Yes o No o44. Do you train all workers on the basic use of fire extinguishers?Yes o No o45. Do you perform fire safety drills? Yes o No oa. If yes, do you keep records of these drills with all pertinent details as to the results of the drills?Yes o No o46.Are fire escapes available for buildings more than one story high?Yes o No o47. Do you have emergency evacuation plans, in the native language(s) of the employees and posted in view of factory workers? Yes o No o48.Is personal protective equipment available at no cost to the employee?Yes o No o49.Do employees have unrestricted access to drinkable water?Yes o No o50.How many functional toilets does this facility have? Male _ Female_51.Do you have a ventilation and lighting system?Yes o No o52.Do you use any materials that generate toxic or hazardous fumes or waste?Yes o No o53.Have any employees become ill due to working with products?Yes o No o54.Is there a supervisor on the floor for each work shift?Yes o No oa.How many supervisors per work shift? 55.Do you allow your employees to associate?Yes o No o56.What efforts does the company make in regards to the environment (i.e., wastewater management, air purification, hazardous material disposal)? 57.Do you provide dormitory or other residential facilities for workers?Yes o No oa. If yes: facility controlled o rental units o other oIf dormitories are provided, please answer questions 58 through 74.58.Number of buildings: _Number of employees that reside in dormitories: _59.Average number of employees in a sleeping room: 60. Approximate space (in square meters) per employee in sleeping room: _61.Are sleeping quarters segregated by gender?Yes o No o62.Are employees provided their own individual mats or sleeping space?Yes o No o63.Are directions for evacuation in the case of fire or other emergencies posted in allsleeping quarters in the native language?Yes o No o64.Does this facility have fire extinguishers in all sleeping quarters?Yes o No o65.Are fire drills conducted?Yes o No o66.Are fire escapes available for buildings more than one-story high?Yes o No o67.Are combustible materials stored in the dormitories or buildings connectedto the dormitories?Yes o No o68.Number of toilets for employees: Male _ Female _69.Are kitchen or laundry facilities provided?Yes o No o70.Do employees pay for the following? (Pay in cash, or payroll deductions)a.If yes, how much?Sleeping quarters:Meals:Transportation:Uniforms:Damaged equipment:Others (please list): 71.Is dormitory access controlled?Yes o No oa. If yes, explain: 72.Are there any curfews on employees?Yes o No oa.If yes, explain: 73.Are employees free to come and go as they please?Yes o No oa.If no, explain: 74.Do employees have unrestricted access to drinkable water?Yes o No o75. Does the factory conduct verifications of production? Yes o No oa. If no, explain: 76. What is the actual garment/unit output on a monthly basis? _77. Does the factory engage in multi-country processing?Yes o No o78. Does the factory have copies of the outward processing arrangements in which it is involved? Yes o No oa. If no, explain: 79. Does the factory maintain accurate records of all transactions with sub-contractors? Yes o No oa. If no, explain: 80. Do the finished products correspond to the purchase orders? Yes o No oa. If no, explain: 81. Can the trail of production be traced via paper from initial order to final export? Yes o No oa. If no, explain: 82. Has the factory been visited by a U.S. official? Yes o No oa. If yes, what was the outcome of the visit?_83. Has the factory been visited by a national official (of that country?) Yes o No o84. If yes, what was the outcome of the visit?Yes o No o85. Does the factory own quota? Yes o No o86. Does the factory buy quota from other factories? Yes o No o87. Does the factory have quota for the categories it is capable of producing? Yes o No o88. Has a statement of policy regarding a drug free environment been developed? Yes o No o89. Has the factory familiarized itself with the characteristics of each type of drug?Yes o No o90. Do you out-source or subcontract any of your production? Yes o No o91. Do you out-source to individuals, families, or collective

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