KANSAS DEPARTMENT OF TRANSPORTATION

WAGE RATE INTERVIEW	PROJECT NUMBER

PRIME CONTRACTOR

SUB-CONTRACTOR

NAME OF EMPLOYEE
DATES EMPLOYED ON PROJECT

FROM TO	WORK CLASSIFICATION	NAME OF SUPERVISOR
HOURS OF WORK

DO YOU WORK OVER

40 HOURS PER WEEK

( YES ( NO	WAGE RATE

S. T. O. T.	HOW PAID

( CASH ( CHECK
IS ANY MONEY DEDUCTED FROM YOUR PAY EXCEPT INCOME TAX AND SOCIAL SECURITY

( YES ( NO (If “yes,” state what types of deductions are made)
WHAT KIND OF WORK DO YOU DO ON THIS PROJECT:

DATE YOU STARTED DOING THIS WORK ON THIS PROJECT	TOOLS USED	APPRENTICES

CRAFT STEP RATE	DATE OF REGISTRATION CARD
DO YOU HAVE PAYMENT RECORDS? ( YES ( NO; RECORDS OF HOURS WORKED? ( YES ( NO

LIST NAMES OF OTHERS DOING SAME WORK:
ADDITIONAL COMMENTS:
IS PERMISSION GIVEN TO DIVULGE TO YOUR EMPLOYER THE INFORMATIONIN THIS STATEMENT? ( YES ( NO
CERTIFICATION OF EMPLOYEE

I HAVE READ THE INFORMATION REPORTED AS OBTAINED FROM ME AND CERTIFY IT TO BE CORRECT TO THE BEST OF MY BELIEF.
DATE AND SIGNATURE OF EMPLOYEE	DATE AND SIGNATURE OF INTERVIEWER
INTERVIEWER’S EVALUATION: IS THE EMPLOYEE PROPERLY CLASSIFIED? ( YES ( NO PROPERLY PAID? ( YES ( NO
REMARKS:
FOR USE OF PAYROLL CHECKER: IS THE ABOVE INFORMATION IN AGREEMENT WITH PAYROLL

DATA AND CONTRACT REQUIREMENTS? ( YES ( NO
COMMENTS:
DATE	TITLE	SIGNATURE

DOT Form No. 209

This form is to be used by the Field Construction personnel on all projects. Interviews shall be made as often as deemed necessary to assure compliance and as a minimum at least every three months during the life of the project with a minimum of one (1) interview per project. An attempt should be made to interview employees of the various crafts during the duration of the project. Small projects may necessitate the interviews being conducted at the start of the project.

To interview the same employee more than once would normally not be necessary.

Wage Rate Interview Forms shall be retained for three (3) years from completion date of the project in the district office.

Wage Rate Interviews shall be taken in privacy and information given shall be confidential.

D.O.T. Form 209

Rev. 2-10

KDOT Form 209

KDOT Form 209

Joe Archer

2011-08-12

City of Overland Park