Overtime-Flsa.com Protecting employees' overtime rights - every hour, every day

First Name *

Last Name *

Middle Initial

Home Street Address *

City *

State *

Zip Code *

Primary Telephone *

Alternate Telephone

Email Address

Name of the Employer

Location(s) where you work(ed)

Type of business

Approx. Number of Employees

Your Job Title(s)

Approx. Number of Employes with your job title or similar job duties

Job Duties Please briefly describe your primary job duties and responsibilities

Date of Employment - Start

Date of Employment - End

Are you a member of a union?

Yes  No

Hours worked per week What is the average or typical number of hours you work/worked per week?

Are you paid

hourly  salary  other

Rate of Pay What is your regular/base rate of pay?

per	hour  week  month  piece

Time Tracked How is/was your time tracked or recorded?

time clock  computer  written  no record

Overtime paid for 40+/wk? Are you paid overtime (time and a half) for hours in excess of 40 in any one week?

Yes  No

Overtime (pt 2) If no, how were you paid for the hours worked in excess of 40 in any one week?

Not at all  straight time  comp time  other

Overtime (pt 3) If you have not been paid time and a half for your hours over 40 in any one week, what reason(s) have you been given for this? Check all that apply to you.

You are exempt You are paid a salary You are a manager, assistant manager or supervisor You didn't get permission or approval in advance You are an independent contractor You didn't work more than 80 hours in the two-week payperiod Your Employer can't afford it You will get a "bonus" or some extra pay later Other reason(s) given

Overtime (pt 4) If you answered "other reasons" above, what were they?

Overtime (pt 5) If you were paid for your overtime, are your bonuses, shift differential and/or other incentive pay included when your employer calculates your overtime pay rate?

Yes  No  Don't Know

Supervise two or more full-time employees?

Yes  No

Interview potential new hires?

Yes  No

Select new hires?

Yes  No

Set/adjust pay rate?

Yes  No

Write job evaluations?

Yes  No

Schedule Employees?

Yes  No

Discipline Employees?

Yes  No

Fire Employees?

Yes  No

Make Key Suggestions? Make suggestions and recommendations as to the hiring, firing, or promotion of other employes that are/were given particular weight?

Yes  No

Make work assignments?

Yes  No

Make decisions on important work-related matters without approval?

Yes  No

Set company policies / practices?

Yes  No

Lunch / Break Pay Are you paid for working through your lunch or other break periods?

Yes  No

Work Off the Clock Have you worked "off the clock" without getting paid for this time?

Yes  No

Have you been told to report fewer hours than you actually worked?

Yes  No

Are you given "comp time" instead of overtime?

Yes  No

If Yes, do you work for a government or state agency?

Yes  No

Additional Comments Additional information and/or your comments:

Referral Source How did you hear about our firm?

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