III. PROFESSIONAL EXEMPTION (5 CFR 551.207) & LEARNED PROFESSIONAL EXEMPTION (5 CFR 551.208)
An employee whose primary duty meets A, B, and C below.
An employee whose primary duty is managing an organizational unit, and who meets both of the conditions below.
U.S. Department of State
FAIR LABOR STANDARDS ACT (FLSA) WORKSHEET
DS-5105
05-2017
Page 1 of 2
A. The work is office or non-manual in nature; and
B. The work is directly related to the management or general business operations of the office or its
customers (rather than "production" functions); and
C. The work includes the exercise of discretion and independent judgment with respect to matters of
significance. Check the box by the appropriate statement(s) below to determine if C is met. One
or more must be checked to meet C.
1. Has authority to formulate, affect, interpret, implement management policies or operating practices;
An employee whose primary duty is work requiring knowledge of an advanced type in a field of science or learning
customarily acquired by a prolonged course of specialized intellectual instruction or work requiring invention, imagination,
originality, or talent in a recognized field of artistic or creative endeavor. Check box for the specialized field required:
PD Number
Title/Pay Plan/Series/Grade
Organization (Bureau/Office/Division)
I. EXECUTIVE EXEMPTION (5 CFR 551.205)
B. Has authority to hire or fire other employees or whose suggestions and recommendations as to the hiring,
firing, advancement, promotion, or any other change of status of other employees, are given particular weight
by higher-level management. To have particular weight, these suggestions and recommendations must be an
expected and frequent part of the employee's job upon which higher level managment must frequently rely.
A. Customarily and regularly directs the work of two or more employees. (Customarily and regularly means
more than occasional, but may mean less than all the time.) and
II. ADMINISTRATIVE EXEMPTION (5 CFR 551.206)
Incumbent Name
SPECIAL INSTRUCTIONS FOR THIS FORM
1. This worksheet must be used in conjuction with FLSA guidance in 5 CFR 551 and in making FLSA
determinations on domestic and U.S. non-foreign area position descriptions effective on or after 10/17/2007.
2. If the employee was assigned to this position before 10/17/2007, and remained in the position after that
date, please fill out the DS-5092 for the period before 10/17/2007 and this form for 10/17/2007 onward.
3. If the employee was assigned to this position on or after 10/17/2007, please complete this form only.
4. For each exemption category, check boxes that apply. If sufficient criteria are checked, mark the
corresponding box in the upper left hand corner for that exemption.
2. Carries out major assignments in conducting the operations of the organization;
3. Performs work that affects the organization's operations to a substantial degree, even if the employee's
assignments are related to operation of a particular segment of the organization;
4. Has authority to commit the employer in matters that have significant financial impact;
5. Has authority to waive or deviate from established policies and procedures without prior approval;
6. Has authority to negotiate and bind the organization on significant matters;
7. Provides consultation or expert advice to management;
8. Is involved in planning long- or short-term organizational objectives;
9. Investigates and resolves matters of significance on behalf of management;
10. Represents the organization in handling complaints, arbitrating disputes, or resolving grievances;
11. Provide a representative duty or responsibility of the position that matches or is equivalent to those
provided in the checked block(s) above.
Law
Medicine
Accounting
Education
Social Work
Other (identify)
Social Science
Instructional Systems
Museum Curator
Architecture
Engineering
Industrial Hygiene
Historian
Archivist
Librarian
Foreign Affairs
OFFICIAL MAKING FLSA DETERMINATION (REQUIRED)
IV. CREATIVE PROFESSIONAL EXEMPTION (5 CFR 551.209)
DS-5105 Page 2 of 2
An employee whose primary duty is the performance of work requiring invention, imagination, originality, or talent in a
recognized field of artistic or creative endeavor rather than routine mental, manual, mechanical, or physical work. This
requirement is generally met by actors, writers, musicians, composers, conductors, and soloists; painters who at most
are given the subject matter of their work and writers who choose their own subjects and hand in a finshed piece of work
to their employers.
Print/Type Name
Organization
FINAL FLSA DETERMINATION
Add additional pages as needed.
A. The application of systems analysis techniques and procedures, including consulting with users to determine
hardware, software, or system functional specifications; and/or
B. The design, development, documentation, analysis, creation, testing or modification of computer systems or
programs, including prototypes, based on and related to user or system design specifications; and/or
ADDITIONAL COMMENTS/EXPLANATORY INFORMATION
A. Serves on a foreign assignment located outside the U.S. and its territories as defined in 5 CFR 551.212; and
1. The employee is permanently stationed in an exempt area and spends all hours of work in a given workweek
in one or more exempt areas; or
B. Serves as a criminal investigator or credentialed DS agent and receives Law Enforcement Availability Pay (See
5 CFR 551.213, 5 CFR 551.214, 5 or CFR 551.216).
C. The design, documentation, testing, creation, or modification of computer programs related to machine operating
systems; and/or
D. A combination of the aforementioned duties, the performance of which requires the same level of skills.
V. COMPUTER EMPLOYEE EXEMPTION (5 CFR 551.210)
An employee whose earnings are $27.63 per hour ($57,663 per year) or more and whose primary duties consist
of one or more of the following:
VI. EMPLOYEE-SPECIFIC EXEMPTION (5 CFR 551.212 thru 5 CFR 551.216)
An employee who:
2. The employee is not permanently stationed in an exempt area, but spends all hours of work in a given
workweek in one or more exempt area; or
Email
Telephone
@State.gov
EXEMPT NONEXEMPT
If you have any questions, please contact your HR service provider or [email protected].
Signature Date (mm-dd-yyyy)
