The employee must read and sign the following acknowledgement:
I understand this multiple employment assignment is approved until ____________________ (maximum six months) and is
contingent upon no change in assigned work schedules, job duties, job titles, in any of the assignments. There is no time conflict
between assignments or duplication of hours worked in any of the assignments on this form. I further understand I must inform
the institution of any change and that such change will require a new Form CT-HR-25h. I understand the result of any change in
information presented on this Form CT-HR-25h may be cause for termination of assignments prior to the aforementioned date.
I ack
nowledge I am not a party to a Personal Services Agreement (PSA) with any state higher education institution or state
agency and will not accept a PSA during the term of the multiple assignments contained on this form.
I u
nderstand I am ineligible for overtime as all assignments listed are FLSA Exempt.
I have reviewed the State Ethics Policy and certify no conflicts of interest exist.
___________________________________________________________________________________________________________
Print Employee’s Name Employee’s Signature Date
EMPLOYING INSTITUTIONS’ CERTIFICATION
Signature below certifies all conditions under C.G.S. Sec. 5-208a are met. A fully executed copy of Form CT-HR-25h must be
retained by all signing institutions for DAS post-audit purposes.
I certify that the assignments specified above
are FLSA Exempt, the primary duty of the assignment(s) is related to teaching, and that
the hours worked in all assignments have been reviewed to preclude duplicate payment. If for any reason there is a change in the
hours and/or days of work indicated, or if there is a change in the employee’s job class, a new Form CT-HR-25h with the required
information will be completed promptly and retained for post-audit. I further certify no conflict(s) of interest exists between the
assignments listed.
Recommend Approval
Yes No 0._________________________________________________________________________________________
Institution Signature of Agency Head/HR Designee Official Job Title Date
Y
es No 1._________________________________________________________________________________________
Institution Signature of Agency Head/HR Designee Official Job Title Date
Yes
No 2._________________________________________________________________________________________
Institution Signature of Agency Head/HR Designee Official Job Title Date
Yes No 3._________________________________________________________________________________________
Institution Signature of Agency Head/HR Designee Official Job Title Date
Y
es No 4._________________________________________________________________________________________
Institution Signature of Agency Head/HR Designee Official Job Title Date
Ye
s No 5._________________________________________________________________________________________
Institution Signature of Agency Head/HR Designee Official Job Title Date
*The U.S. Department of Labor FLSA Regulations is the authority on eligibility for overtime when an employee is dually employed.
**The Form CT-HR-25h must be completed before the employee begins multiple assignments.
