FLSA Exempt/Nonexempt Questionnaire

Note  to employee: To help determine that your current position is properly classified as an exempt or nonexempt position, please complete this survey. If you have any questions, check with the human resource (HR) department. Please return the completed questionnaire to the HR department whose staff makes the final classification decision. HR staff will inform you and your supervisor of the final decision.

Employee name: _______________________________

Date completed: _______________________________

Position: ________________________________

Department: ________________________________

Supervisor: ________________________________

1. How are you paid? ☐ Salary  ☐ Hourly

If salary, what is your base salary paid per paycheck (this company pays on a [monthly, semimonthly, biweekly, weekly] basis): ____________________

2. Do you have an academic degree (undergraduate and graduate)? ☐ Yes  ☐ No

If yes, please list degree(s) below:

_________________________________________________________

3. Do you supervise employees? ☐ Yes ☐ No

If yes, how many? __________

List the job titles of employees you supervise:

_________________________________________________________

4. Do you work regular hours? ☐ Yes ☐ No

Describe__________________________________________________________

5. Do you exercise discretion and independent judgment in matters of significance to perform your work? Prior to responding, please review the following clarification from the Department of Labor.

☐ Yes  ☐ No

In general, the exercise of discretion and independent judgment involves the comparison and the evaluation of possible courses of conduct and acting or making a decision after the various possibilities have been considered. The term must be applied in the light of all the facts involved in the employee's particular employment situation and implies that the employee has authority to make an independent choice, free from immediate direction or supervision. Factors to consider include, but are not limited to:

• Whether the employee has authority to formulate, affect, interpret, or implement management policies or operating practices.

• Whether the employee carries out major assignments in conducting the operations of the business.
• Whether the employee performs work that affects business operations to a substantial degree, even if the employee's assignments are related to operation of a particular segment of the business.
• Whether the employee has authority to commit the employer in matters that have significant financial impact.
• Whether the employee has authority to waive or deviate from established policies and procedures without prior approval.
• Whether the employee has authority to negotiate and bind the company on significant matters.
• Whether the employee provides consultation or expert advice to management.
• Whether the employee is involved in planning long- or short-term business objectives.
• Whether the employee investigates and resolves matters of significance on behalf of management.
• Whether the employee represents the company in handling complaints, arbitrating disputes or resolving grievances.

The fact that an employee's decisions are revised or reversed after review does not mean that the employee is not exercising discretion and independent judgment. 

The term "matters of significance" refers to the level of importance or consequence of the work performed. An employee does not exercise discretion and independent judgment with respect to matters of significance merely because the employer will experience financial losses if the employee fails to perform the job properly. Similarly, an employee who operates very expensive equipment does not exercise discretion and independent judgment with respect to matters of significance merely because improper performance of the employee's duties may cause serious financial loss to the employer.

If yes, provide examples:  __________________________________________________

_______________________________________________________________________

 

6. Which activities do you regularly engage in? Check all that apply.

• • Manage a department or facility.
  • Hire or discharge employees or make significant recommendations regarding employment actions.
  • Perform administrative or office functions or nonmanual work directly related to the management or general business operations.
  • Perform work and provide professional services that require advanced knowledge (beyond high school) in a field of science or learning.
  • Use creative talents in providing services or creating products.
  • Apply computer systems analysis techniques and procedures and/or design, develop, document, analyze, create, test or modify computer systems or programs.
  • Am customarily engaged away from employer's place of business making sales or taking orders for services or products.

7. Are you responsible for any special projects (not included in activities above)?
☐ Yes ☐ No

If yes, please list: ________________________________________________________


This section to be completed by the Human Resource Department

Based on this survey and other relevant information (job description, employee and supervisor interviews), this position is classified as:

☐ Exempt ☐ Nonexempt

If exempt, type of exemption: __________________________________________

Date employee and supervisor informed of decision: ___________________________

If this classification is a change, indicate actions taken: _________________________

Name of person completing this section: __________________________________________

Signature: _________________________________

Date: _____________________________________