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INSTRUCTIONS & IMPORTANT REMINDERS FOR COMPLETING THE FORM

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INSTRUCTIONS & IMPORTANT REMINDERS FOR COMPLETING THE FORM CT-HR-25
May 2017
Review General Letter 204 and the “Dual Employment Processing” Job Aid before completing.
An employee has just one FLSA Status. For the purpose of dual employment, it is imperative
the employee’s FLSA Status has been determined in accordance with the US DOL FLSA
Regulations. Questions concerning the FLSA Status of a position are to be directed to DAS
SHRM – Classification & Pay Unit.
In accordance with the “Approvals Procedure” in General Letter 204, DAS SHRM – HR
Business Rules & Central Audit Unit must review and approve the Form CT-HR-25 (“CT-HR-
25”) when the FLSA Status is Nonexempt or when the hours of the assignments are the same.
This review will be expedited when (all) agencies are able to certify via the CT-HR-25 the
employee will never exceed 40 combined hours per week.
The employee must not begin work in the new assignment until all necessary approvals
are on file*.
The agency hiring a current state employee initiates the completion of the CT-HR-25 (when the
employee intends to remain employed in his/her current job beyond the start date in the new
assignment). Refer to the Core-CT HRMS “Dual Employment Processing” Job Aid.
• Enter the date the CT-HR-25 is completed, the name of employee, the employee’s (Empl)
ID, and the FLSA Status of the employee.
• Next to the appropriate Core-CT Record, each agency specifies the following:
o Agency name and assignment work location
o Job title and/or major duties of the position
Check the box if the DAS class specification reflects the primary duties of the
employee’s assignment.
When the job title is Faculty, Instructor, Lecturer, Substitute Teacher or Graduate
Assistant where the primary duty of the assignment is teaching, the title alone may
be listed.
For all other assignments, list the title and major duties to be performed by the
employee. (Attach a separate sheet of paper for additional duties, as necessary.)
o For Higher Education only:
Complete the course information for higher education teaching assignments.
Enter load hours; combined load hours cannot result in eligibility for additional
benefits
Indicate when an employee is teaching an online class
o The start date of the assignment
Higher Education teaching assignments only: This date may or may not be the
start of the semester. (Do not enter the semester start date unless the employee
is actually scheduled to teach on that date. Rather, enter the actual date the
employee is first scheduled to work.)
o Indicate if the employee is working in an occasional or sporadic work schedule
For online and occasional or sporadic assignments: after discussing the hours of
work for each assignment with the employee and ensuring the dual assignment is
appropriate relative to the employee’s other assignment(s), indicate the schedule
varies and will not conflict with other assignments.
APPROVAL PROCESS
Once (all) agencies involved with the dual or multiple employment have provided the required
information pertaining to each assignment, the CT-HR-25 must be reviewed and signed by the
employee and the Agency Head or designee at each agency.
Agencies may approve this form when the appointment(s) are made in accordance with General
Letter 204 and the employee’s FLSA Status has been determined to be Exempt. Approvals from
Fiscal Managers (at each agency involved with the dual or multiple assignment) and from DAS
SHRM are required if there is any chance of overtime.
* Exceptions may be made when all jobs involve teaching assignments or in an emergent
situation when the employee’s FLSA Status is Exempt and when it is imperative for coverage,
i.e., Substitute Teacher. In such situations, the fully executed form must be on file within seven
(7) business days from the first day the employee worked in the assignment.
Statewide Human Resources Management
Dual Employment Request Form
Form #: CT-HR-25
Revised: 5/2017
The
hiring agency initiates a Dual Employment Request (Form CT-HR-25) when hiring a current state employee
into another state assignment (and the employee intends to continue working in his/her existing assignment). This
form is required in accordance with C.G.S. Section 5-208a and General Letter 204. See Instructions on Page 1.
Core-CT
Record #
Agency and
Assignment
Work Location
Job title or Major Duties
Check if duties reflected on
DAS class specification (see
Instructions for more information)
Official Job Title
or
Course ID
(Higher Education)
Higher Ed
Load Hrs.
Anticipated 1
st
Day
of work in (new)
Assignment
0
1
2
3
Today’s Date
Name of Employee
Empl ID
FLSA Status
Core-CT
Record #
Online
Course?
Occasional
or
Sporadic?
Work
Schedule
varies; no
conflict
Course/
Assignment
Schedule
Workweek: Seven consecutive days beginning on
Friday at 12:01 AM through midnight Thursday
Fri.
Sat.
Sun.
Mon.
Tues.
Wed.
Thur.
0
Start Time:
Unpaid
Break:
End Time:
1
Start Time:
Unpaid
Break:
End Time:
2
Start Time:
Unpaid
Break:
End Time:
3
Start Time:
Unpaid
Break:
End Time:
The employee must read and initial each of the following statements as they apply to the employee’s
dual/multiple employment assignments and acknowledge all information by signing below:
G
ENERAL:
___I have been advised General Letter 204 – Dual Employment is available online and understand I should
address my questions about dual/multiple employment to the Human Resources Office in any of the employing
agencies listed on this form.
___
I have reviewed all of the assignments on this form and attest the information presented reflects all of my
current work assignments with the State of Connecticut (including the Judicial and Legislative Branches and
quasi-public agencies where employees are construed to be state employees).
___
I have reviewed the work schedule information and confirm there is no time conflict between assignments
or duplication of hours worked in any of the assignments on this form. I understand I am not to perform work
for one assignment while working in another assignment and that I cannot take paid or unpaid leave time from
one assignment in order to travel or perform duties of another assignment.
___
I have reviewed the State Ethics Policy, have had an opportunity to raise questions to the Ethics Officer in
my agency, and certify no conflicts of interest exist.
C
OMPENSATION:
___I understand I am ineligible for overtime as my FLSA Status is Exempt
___I understand I am eligible for overtime as my FLSA Status is Nonexempt
___I further understand that I will receive overtime pay for hours actually worked over 40 in a week and
that I should inform Human Resources when I work more than the scheduled hours indicated on this form.
___I understand the overtime rate for hours worked over 40 in a week will vary because it is based on the
number of hours worked in each assignment (“weighted average”). The approximate overtime rate is
calculated at _______ hourly.
We
ighted Average Overtime Calculation
a.) Job 1 # Hours x Pay Rate + Job 2 # Hours x Pay Rate = Total Straight-time Pay
b.) Total Straight-time Pay / Total Hours = Weighted Average Regular Rate of Pay
c.) Weighted Average Regular Rate of Pay / 2 = Sub-total
d.) Sub-total from ‘c.’ x Hours over 40 = Total Overtime Amount
Reason: FLSA requires the payment of overtime at time and one half for all hours actually worked over 40
in a week to eligible employees. The hours over 40 have already been paid as straight time by each agency;
now the additional “half” must be added to the straight time already paid, using the weighted average rate.
___I
understand this dual/multiple employment assignment is approved until _________ (Maximum length:
either the end of the semester for higher education teaching assignments or up to 12 months for non-higher
education assignments or higher education non-teaching assignments).
___I have been informed the continuation of my eligibility to work in the dual assignment is contingent upon
there being no change to assigned work schedules, job duties or job titles in any of the assignments indicated,
and my future acceptance of an additional assignment(s). I understand that I must immediately inform
Human Resources of any change before it occurs and that implementation of such change will require a new
CT-HR-25. I understand the result of any change in information presented on this CT-HR-25 may be cause for
termination of assignment(s) prior to the aforementioned date.
_________
______________________________________________________________________________
Print Employee’s Name Employee’s Signature Date
EMPLOYEE ACKNOWLEDGEMENT
By signing this form, agencies certify the following:
• Duties and responsibilities of both the primary and secondary positions have been reviewed in accordance with
General Letter 204 and by applying the US Department of Labor (US DOL) Fair Labor Standards Act (FLSA)
Tests for exemption to determine overtime liability.
o Following the review of duties, I further certify (check one):
___The employee’s FLSA Status is Exempt; the employee will never incur overtime.
___The employee’s FLSA Status is Nonexempt but the combined hours of all assignments are far
below 40 and will never exceed 40 in a week. Therefore, there is no possibility of the employee
incurring overtime.
___The employee’s FLSA Status is Nonexempt and there is a possibility the combined hours of
all assignments may exceed 40 in a week. Therefore, the employee may incur overtime. A weekly
review of all hours actually worked will be conducted by all agencies. Approval from each Fiscal
Director has been received; DAS approval is required.
___The employee’s FLSA Status is Nonexempt. The employee will definitely work more than 40
combined hours in a week. A weekly review of all hours actually worked will be conducted by all
agencies. Approval from each Fiscal Director has been received; DAS approval is required.
• Duties specified are outside the responsibility of the employee’s principal employment.
• Hours worked are documented accurately and have been reviewed to preclude duplicate payment.
• No conflicts of interest exist between services performed.
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 or dual/multiple assignments, a new CT-HR-25 with the required information will be
completed, reviewed and approved, as appropriate by all agencies, Fiscal Managers and DAS. The new fully
executed CT-HR-25 will be retained for post-audit.
Approvals
Signatures below certify all conditions under C.G.S. Sec. 5-208a, General Letter 204 and FLSA Regulations are
met. A fully executed copy of the CT-HR-25 along with all relevant materials must be retained by each agency
for DAS post-audit purposes.
This assignment is approved through close of business _____________________.
Core-CT Record 0:
___ Yes ___No ___________________________________________________________________________________
Agency Signature of Agency Head/HR Designee Official Job Title Date
___Approval Fiscal Manager: _________________________________________________________________________
Signature Official Job Title Date
Core-CT Record 1:
___ Yes ___No ___________________________________________________________________________________
Agency Signature of Agency Head/HR Designee Official Job Title Date
___Approval Fiscal Manager: _________________________________________________________________________
Signature Official Job Title Date
Core-CT Record 2:
___ Yes ___No ___________________________________________________________________________________
Agency Signature of Agency Head/HR Designee Official Job Title Date
___Approval Fiscal Manager: _________________________________________________________________________
Signature Official Job Title Date
Core-CT Record 3:
___ Yes ___No ___________________________________________________________________________________
Agency Signature of Agency Head/HR Designee Official Job Title Date
___Approval Fiscal Manager: _________________________________________________________________________
Signature Official Job Title Date
___Approval from DAS: _____________________________________________________________________________
Signature Comments, if any Date
EMPLOYING AGENCY’S OR AGENCIES’ CERTIFICATION
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INSTRUCTIONS & IMPORTANT REMINDERS FOR COMPLETING THE FORM

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Completed 2 September 2020

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