I have worked off the clock during the past three years at this employer:
  No
  Yes
If yes, how long:

I have been asked by a supervisor to work off the clock:
  No
  Yes
If yes, how often:

I have worked during my lunch breaks during the past 3 years without pay:
  No
  Yes
If yes, how often:

I have been warned by a supervisor that I will be disciplined if I do not clock out for my lunch break even though I was working:
  No
  Yes

I have had time manually deducted from my time sheet during the last 3 years even though I had worked the time that was deducted:
  No
  Yes
If yes, how often and how much time:

Supervisors know I have worked without pay during the past 3 years:
  No
  Yes
If yes, how do they know:

I have worked more than 40 hours during a week and received straight time pay:
  No
  Yes
If yes, when:

I have worked before I clocked in without pay:
  No
  Yes
If yes, how often and how much:

I have worked off the clock to do paperwork:
  No
  Yes
If yes, how often and how much:

I have worked off the clock to do inventory:
  No
  Yes
If yes, how often and how much:

I have been told my management or supervisors with words to the effect "get the job done, I don't care how you do it but no overtime":
  No
  Yes

I have known other employees that have worked off the clock in the last 3 years:
  No
  Yes

Names:

Circumstances:

I have worked 40 or more hours on weeks when I have worked off the clock or had hours deducted:
  No
  Yes
If yes, how often and how much:

Comments:

I understand that this information is being provided for purposes of investigating possible claims under Federal and State Law by Counsel for UFCW Local 700.

I authorize UFCW to provide this information to their attorneys.

Name:
Date: