OVERTIME CLAIM EVALUATION QUESTIONNAIRE
In order to allow us to properly evaluate your individual situation, please answer the following questions as accurately and completely as possible. After you submit your information, we will respond promptly. Thank you.
NOTE: An Asterisk (*) Indicates REQUIRED Information.
First Name* |
|||||
Middle Name |
|||||
Last Name* |
|||||
Street Address* |
|||||
|
|||||
Home Phone: |
|||||
Work Phone: |
E-Mail 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 Employees with your job title or similar job duties: |
|||||
Please briefly describe your primary job duties and responsibilities. |
|||||
Approx. number of Employees with your job title or similar job duties: |
|||||
Dates of employment: Start End |
|||||
Are you a member of a union? Yes No |
|||||
Average or typical number of hours you work/worked per week? |
|||||
Are you paid Hourly Salary Other |
|||||
Your regular rate of pay: $ |
|||||
How is/was your time tracked or recorded? |
|||||
Are/were you paid overtime (time and a half) for hours in excess of 40 in any one week? Yes No |
|||||
If No, how were you paid for the hours worked in excess of 40 in any one week? |
|||||
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: |
|||||
If you are 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 |
|||||
In your job, do/did you:
|
|||||
Are you relieved of all duties for at least half an hour for lunch? |
|||||
If No, are you paid for working through your lunch or other break periods? Yes No |
|||||
Have you worked "off the clock" without getting paid for this time? Yes No |
|||||
If Yes, how often? Daily Weekly Monthly Rarely |
|||||
Have you been told to report fewer hours than you actually worked? Yes No |
|||||
If Yes, how often? Daily Weekly Monthly Rarely |
|||||
Do you work shift duty? Yes No |
|||||
If so, are you paid to attend pre-shift meetings? Yes No |
|||||
Are you paid for the time you spend putting on and taking off your protective gear or uniform? Yes No |
|||||
Are you given "comp time" instead of overtime? Yes No |
|||||
If Yes, do you work for a government or state agency? |
|||||
Have you been required to attend meetings or training classes for which you are not paid? Yes No |
|||||
Are you required to be "on call" and report to work in an hour or less if called? Yes No |
|||||
Are you required to travel from one work location to another? |
|||||
If Yes, are you paid for your travel time? Yes No |
|||||
Do you participate in a tip pool? Yes No |
|||||
Has your employer been investigated by the Department of Labor in the last 2 years? Yes No Don't know |
|||||
Additional information and/or your comments: |
|||||
If you used a search engine to find this site, what search term(s) did you use? |
|||||
Disclaimer & Notice |
|||||
The information contained on this site is not and is not intended to be legal advice. You should always consult an attorney for individualized advice about your particular situation. The use of this site and/or the submission of any information via this site does not create a contract or an attorney-client relationship. |
|||||
| include 'http://inbox.lawinfo.com/index.cfm?fuseaction=Form.captcha2'; ?> |