DID YOU WORK MORE THAN 40 HOURS IN A WORKWEEK?

 

WERE YOU OFFERED A PER DIEM OR BONUS?

 

DO YOU HAVE A WRITTEN AGREEMENT SETTING OUT THE PER DIEM OR BONUS OF YOUR EMPLOYMENT OR ASSIGNMENT?

Initial Overtime Consultation Request

Healthcare Professional

Bonuses,Per diem, other non-discretionary bonuses
Name

Employer whose pay practices you want examined

MM slash DD slash YYYY
MM slash DD slash YYYY

Compensation package

Overtime Criteria
Check all the boxes that apply to you
Overtime Criteria
Check all the boxes that apply to you
Were any of the bonuses or per diems reduced based on hours/shifts worked
Potential Documentary Evidence
This field is for validation purposes and should be left unchanged.