Item 1: salary threshold
Whether the annual rate of basic pay for the position is equal to or greater than $23,660. A note says what the rate of basic pay includes. See 5 CFR 551.203.
GSA5023
FLSA Exemption Determination Checklist - Executive Exemption
- Agency
- GSA
- Revision
- Rev. 11/2017
- Fillable fields
- 6
- Pages
- 2
- Official source
- GSA form page
- Checked
- October 20, 2026
GSA Form 5023: FLSA Exemption Determination Checklist, Executive Exemption
GSA Form 5023, FLSA Exemption Determination Checklist, Executive Exemption Checklist, is a General Services Administration (GSA) form, edition 11/2017, and GSA hosts it in its forms library. It is a two-page checklist of YES and NO questions about a position, leading to one result: EXEMPT or NON-EXEMPT under the FLSA executive exemption.
The eight items cover a salary threshold, whether the position's primary duty is management, whether the employee customarily and regularly directs the work of two or more other employees, and authority or particular influence over hiring and firing, with references to 5 CFR 551.203, 5 CFR 551.104 and 5 CFR 551.205. A NO answer routes to item 8. The form says the employee should be marked as exempt only if you answered YES to all questions.
The PDF prints no name, signature, filing address or OMB number. You can fill it out free in your browser on this page and download the result without an account.
What's on GSA Form 5023
Items 2, 4 and 6: routing
Each routing row says to move on to the remaining questions after a YES, and to go to item 8 after a NO.
Item 3: primary duty of management
Two parts joined by AND: a. work directly related to management activities the form lists, such as directing the work of employees and planning the work, and b. that work is the primary duty.
Item 5: directs two or more employees
Whether the employee customarily and regularly directs the work of two or more other employees. See 5 CFR 551.205.
Item 7: hiring and firing
Two options joined by OR: a. authority to hire or fire other employees, or b. suggestions and recommendations on hiring, firing, advancement or promotion that are given particular weight by higher-level management.
Item 8: result
Under the heading Executive Exemption, an EXEMPT box and a NON-EXEMPT box.
Eight numbered items. Items 2, 4 and 6 are routing rows.
How to complete GSA Form 5023
- 1
Check the pay rate
Answer item 1. The form says the rate of basic pay includes locality payments and special rate supplements before deductions, and does not include premium payments, differentials, and allowances.
- 2
Answer the management questions
Check YES or NO for items 3a and 3b. Item 3b says the work is the primary duty when it takes more than 50% of work time, or under three conditions printed on the form.
- 3
Answer the supervision question
Check YES or NO for item 5. The form says an employee who shares supervisory responsibilities has at least the equivalent of full-time supervisory responsibility over two employees.
- 4
Answer the hiring and firing question
Check YES or NO for item 7, which is met by either authority to hire or fire, or recommendations given particular weight.
- 5
Follow the routing and mark the result
A NO answer goes to item 8. The form says to mark the employee exempt only if you answered YES to all questions, and otherwise says the employee is marked non-exempt.
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What the form says and does not say
Where it goes
The PDF gives no filing address or routing instructions, and prints no name, signature or date lines.
Pay figure as printed
The 11/2017 edition prints $23,660 as the annual rate of basic pay in item 1.
Regulations the form cites
5 CFR 551.203, 5 CFR 551.104, 5 CFR 551.205, 5 CFR part 531, Subpart F, and 5 CFR part 530, Subpart C.
What the PDF does not include
The PDF prints no OMB number, burden estimate or privacy notice, and GSA's page lists no authority or regulation for the form.
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Who uses GSA Form 5023?
The form does not name a job title for the person who completes it. It is written about a position and the employee in it.
Official sources and the blank
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Questions about Form GSA5023
Who issues GSA Form 5023?
The footer prints General Services Administration and GSA 5023 11/2017. GSA hosts the form in its forms library.
What pay figure does GSA Form 5023 print?
Item 1 asks whether the annual rate of basic pay for the position is equal to or greater than $23,660, and cites 5 CFR 551.203.
What management activities does the form list?
Item 3a lists activities such as interviewing, selecting, and training employees, setting rates of pay and hours of work, directing the work of employees, appraising productivity, handling complaints and grievances, disciplining employees, planning the work and planning and controlling the budget.
What does the form say about directing two or more employees?
Item 5 says the employee does not merely assist the manager of a department and supervise others only in the manager's absence. With shared supervision, it gives the example of an employee who supervises four full-time employees for four hours a day.
What does the hiring and firing question cover?
Item 7 asks whether the employee has the authority to hire or fire other employees, or whether the employee's suggestions and recommendations on hiring, firing, advancement, promotion or other changes of status are given particular weight by higher-level management.
When is the employee marked exempt?
The form says the employee should be marked as exempt only if you answered YES to all questions. If you answered NO to any question, it says the employee does not meet the definition and is marked non-exempt.
Does GSA Form 5023 have a signature line?
No. The PDF prints no name, signature or date lines, only the questions and the YES, NO, EXEMPT and NON-EXEMPT boxes.