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Human Resource Services
Overtime Usage Request & Authorization
Certification of Performance of Overtime
HRS Director’s Office
555 S Howes Street, Suite 204
Campus Delivery 6004
Instructions
1. One form is to be completed in triplicate for each employee or group of employees working overtime. This
form must be signed by a department head or other authorized approving individual before any overtime work
is performed.
2. The original copy of this form is sent, after approval, to the administrative section of the approving individual.
3. The requesting supervisor receives and retains two copies until the authorization has expired and then completes
and sends both to the administrative section. If no work is performed under an authorization, the supervisor’s
copies are sent to the administrative section marked “Not Used”.
4. The administrative section will match the supervisor’s copies of the authorization and certification form to the
original already received. All copies will be compared to insure that total hours certified do not exceed the
maximum number authorized.
5. After checking, the administrative section will file the original and copy. A copy shall be given to each
employee who works the requested overtime. Hours certified will be posted to the individual employee record
and/or Time Sheet.
6. In emergency situations overtime may be authorized by the supervisor prior to an official request. However, this
form shall be filled out and signed by the appropriate officials as soon as possible after commencement of the
work.
TO: Authorization No.
Date:
Employee
Overtime Needed
Maximum
Manhours
Needed
Overtime Worked
Total Overtime
Hours Worked
Date
Time
AM PM
Date
Time
AM PM
Justification
Requested By
Supervisor Department or Section
Approved By
Dept Head or Authorized Official Date
This is to certify that the above requested overtime hours have been worked.
Certified By
Supervisor Date