GSA5030

FLSA Exemption Determination Checklist - Temporarily Performing Different Duties Exemption

Agency
GSA
Revision
Rev. 11/2017
Fillable fields
17
Pages
3
Official source
GSA form page
Checked
October 20, 2026
Fill GSA5030 online
Page 1 of form GSA5030

GSA Form 5030: FLSA Exemption Checklist, Temporarily Performing Different Duties

GSA Form 5030, FLSA Exemption Determination Checklist, Temporarily Performing Different Duties Exemption, is a three-page General Services Administration (GSA) form printed as GSA 5030 11/2017. GSA hosts it in its forms library. The form prints no OMB number, and GSA's page lists no authority or regulation.

The form says the checklist applies only when an employee performs work or duties that are not consistent with the employee's primary duties for more than 30 consecutive calendar days, the "30-day test" in 5 CFR 551.211. It asks whether the classification changed, whether pay was recalculated, and how emergency situations are handled.

Question 14 records the result: NO CHANGE, or a TEMPORARY CHANGE to exempt or non-exempt status with its dates and the exemption that applies. You can fill it out free in your browser on this page and download the result without an account.

Top of page 1 of GSA Form 5030: FLSA Exemption Checklist, Temporarily Performing Different Duties, as printed by GSA

What's on GSA Form 5030

Question 1: the 30-day test

Whether the employee has performed work or duties not consistent with their primary duties for more than 30 consecutive calendar days. Question 2 says to STOP on a NO.

Questions 3 to 5: change in classification

Whether the primary duties were different enough to change the classification, and whether the supervisor was not breaking up the work schedule to avoid reassessment.

Question 6: recalculating pay

Whether the classification was changed for the entire period of temporary work and total pay recalculated retroactive to the beginning of that period.

Questions 7 to 10: emergency situations

Whether the agency has determined an emergency situation exists, and whether the employee's normal primary duties are non-exempt.

Questions 11 to 13: exempt employees in an emergency

Whether an exempt employee is temporarily performing non-exempt work during the emergency period, then the same pay recalculation questions as question 6.

Question 14: exemption status

NO CHANGE, or TEMPORARY CHANGE with a box for temporarily exempt and a box for temporarily non-exempt, each with from and until dates and the exemption.

How to complete GSA Form 5030

  1. 1

    Apply the 30-day test

    Answer question 1. The form says that on a NO you STOP, because the checklist is used only when temporary work exceeds 30 consecutive calendar days.

  2. 2

    Attach supporting evidence

    Question 1 asks to attach documentary evidence to support the answer.

  3. 3

    Decide whether the classification changed

    A NO to question 3 goes to question 14, marked No Change. A YES goes on to questions 5 and 6.

  4. 4

    Check the schedule is not broken up

    The form says an agency may not assign exempt employees non-exempt work for 29 consecutive calendar days, return them to exempt duties for two or three days, then assign them again for another 29 days.

  5. 5

    Complete the emergency questions if they apply

    Questions 7 to 13 are for emergency situations. The form says that on a NO to question 7 you STOP, as that section does not apply.

  6. 6

    Record the result in question 14

    Mark No Change, or check the temporary change box and record the dates, the end date of the temporary duties and the exemption that applies.

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What the form says

Where it goes

The form gives no filing address, signature line or routing instructions.

Pay recalculation

Where the classification changed, the form asks whether total pay was recalculated so that, where applicable, temporarily non-exempt employees receive FLSA overtime pay and temporarily equivalent overtime pay.

Similar positions

The form says agencies do not have to make a reassessment for employees who temporarily work in other identical or similar positions with the same basic duties and exemption status.

Regulations cited

5 CFR 551.211 for the 30-day test and 5 CFR 551.203 on pay rates.

Related forms

Who uses GSA Form 5030?

  • Whoever reassesses exemption status

    The questions ask whether a process was set up to reassess exemption status and whether pay was recalculated. The form does not give that person's title.

  • Supervisors and HR

    Question 1 asks whether there are procedures for supervisors to notify HR whenever their employees temporarily perform different duties, and asks for documentary evidence to be attached.

  • Employees on different duties over 30 days

    The checklist covers an employee who performs duties not consistent with their primary duties for more than 30 consecutive calendar days. The form says it is not used otherwise.

  • Employees doing emergency work

    Questions 7 to 13 cover temporary work in connection with an emergency situation the agency has determined exists.

The form does not name the office that completes it. Its questions ask about supervisors, HR and the reassessment of an employee's exemption status.

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Questions about Form GSA5030

Who issues GSA Form 5030?

It is a General Services Administration form, printed as GSA 5030 11/2017. GSA hosts it in its forms library.

When is GSA Form 5030 used?

The form says it applies only when an employee performs work or duties not consistent with the employee's primary duties for more than 30 consecutive calendar days, the "30-day test". It cites 5 CFR 551.211.

Is a reassessment needed for a similar position?

The form says agencies do not have to make a reassessment for employees who temporarily work in other identical or similar positions that have the same basic duties and exemption status as their regular positions.

What does the form say about splitting up temporary work?

It says an agency may not assign exempt employees to perform non-exempt work for 29 consecutive calendar days, return them to their exempt duties for two or three days, then assign them again for another 29 days.

How does an emergency affect exemption status?

The form says a non-exempt employee remains non-exempt whether performing non-exempt or exempt work during the emergency, and an exempt employee becomes non-exempt for any workweek in which the primary duties for the emergency work are non-exempt.

Does the pay rate matter?

The form says employees with a pay rate of any amount may be classified as exempt if they meet the requirements for an appropriate exemption when temporarily performing different duties. It cites 5 CFR 551.203.