FLSA EXEMPT FORM - Kentucky
FLSA EXEMPT FORM
Employee Name
Social Security Number
Class Code
Date of Test
EXECUTIVE ANSWERS (CIRCLE)
1. Yes No
Management Activities Factors: a b c d e f g h i other________
2. Yes No
3. Yes No
4. Yes No
ADMINISTRATIVE ANSWERS (CIRCLE)
1. Yes No
2. Yes No
Factors: a b c d e f g h i j k other_______________
3. Yes No
PROFESSIONAL ANSWERS (CIRCLE)
1. Yes No
2. Yes No
3. Yes No
ALL ANSWERS IN ANY ONE CATEGORY MUST BE "YES" TO BE EXEMPT.
FINAL FLSA STATUS
EXEMPT NON-EXEMPT
I certify that, pursuant to the Fair Labor Standards Act, the answers above correctly reflect the duties performed by the above named employee.
NAME OF SUPERVISOR
Signature Date
c: Personnel File
................
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