FAIR LABOR STANDARDS ACT (FLSA) WORKSHEET - DS-5105 - Exemption Determination Sections

Sep 18, 2026

Uploaded by Franzy

U.S. Department of State form DS-5105 (11-2024) used to document Fair Labor Standards Act (FLSA) exemption determinations for domestic and U.S. non-foreign area positions. Provides instructions for employees assigned before or on/after 10/17/2007, and outlines exemption criteria under executive, administrative, professional, learned professional, creative professional, computer employee, and employee-specific exemptions under 5 CFR 551. Includes conditions describing primary duty requirements and checkboxes for exemption categories.

LanguageEnglish

CategoryResearch & Report

FormatPDF

Pages2

Reading Time5 min

AccessFree to download

SPECIAL INSTRUCTIONS FOR THIS FORM

I. EXECUTIVE EXEMPTION (5 CFR 551.205)

II. ADMINISTRATIVE EXEMPTION (5 CFR 551.206)

III. PROFESSIONAL EXEMPTION (5 CFR 551.207) & LEARNED PROFESSIONAL EXEMPTION (5 CFR 551.208)

IV. CREATIVE PROFESSIONAL EXEMPTION (5 CFR 551.209)

V. COMPUTER EMPLOYEE EXEMPTION (5 CFR 551.210)

VI. EMPLOYEE-SPECIFIC EXEMPTION (5 CFR 551.212 thru 5 CFR 551.216)

U.S. Department of State FAIR LABOR STANDARDS ACT (FLSA) WORKSHEET | PD Number | | | | Incumbent Name | | | --- | --- | --- | --- | --- | --- | | Title/Pay Plan/Series/Grade | | | | | | | Organization (Bureau/Office/Division) | | | | | | | 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. | | | | | | | I. EXECUTIVE EXEMPTION (5 CFR 551 .205)
An employee whose primary duty is managing an organizational unit, and who meets both of the conditions below. | | | | | | | | | 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
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. | | | | |
II. ADMINISTRATIVE EXEMPTION (5 CFR 551.206) An employee whose primary duty meets A, B, and C below.

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;
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. | | | | | | | | III. PROFESSIONAL EXEMPTION (5 CFR 551.207) & LEARNED PROFESSIONAL EXEMPTION (5 CFR 551.208) | | | | | | 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 fie

FAQs

What is the purpose of the DS-5105 worksheet?

It supports making FLSA exemption determinations for positions by documenting which exemption category criteria are met based on primary duty and listed conditions.

How should the form be used for employees assigned before 10/17/2007 versus on or after that date?

If assigned before 10/17/2007 and remaining after, complete DS-5092 for the period before 10/17/2007 and complete this form for 10/17/2007 onward. If assigned on or after 10/17/2007, complete this form only.

Which exemption categories are covered in the worksheet?

Executive, administrative, professional and learned professional, creative professional, computer employee, and employee-specific exemptions under 5 CFR 551.212 through 5 CFR 551.216.

Sep 18, 2026

Uploaded by Franzy