3355 West Alabama
Suite 1010
Houston, Texas 77098
Telephone: 866-772-1997
Facsimile: 713-522-9977

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.

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email or Phone

First Name*

Middle Name

Last Name*

Street Address*

City*

State*

Zip Code*

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:    $
    per   Hour Week Month Piece

How is/was your time tracked or recorded?
Time Clock Computer Written No Record

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?
Not at all Straight time Comp time Bonus Other

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 pay period
You don't get paid for travel time (between jobs or overnight)
You will get a "bonus" or some extra pay later
Your Employer can't afford it
Other reason(s) given   

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:

  • 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 suggestions and recommendations as to the hiring, firing or promotion of other employees 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

Are you relieved of all duties for at least half an hour for lunch?
   Yes No

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?
   Yes No

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?
   Yes No

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

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Disclaimer & Notice
By submitting this form, you understand that this information is being submitted only so that it may be reviewed and considered by attorney Law Offices of Douglas B. Welmaker, P.C. Submitting this form does not establish an attorney client relationship and does not obligate us to represent you. We may or may not be able to undertake representation on your behalf, but we will gladly review the information you provide and respond to you.

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.

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