Attorneys

What type of claim do you believe you have? Check all that may apply:

Wrongful termination
Sexual harassment/discrimination
Racial Crimination
Age discrimination
Disability discrimination
Retaliation
Breach of contract
Whistle blower
Failure to pay all wages due or overtime
Failure to provide meal/rest periods

Name of employer:

Approximate number of employees:

Date hired:

Job position:

Compensation:

Have you been fired?

Yes
No

If so, date of termination:

Are you about to be fired?

Yes
No

Briefly explain:

What reason did your employer give you for the termination?

Did you agree with the reason given by the employer?

Yes
No

If not, why do you believe your employer terminated you?

If you resigned, date of resignation:

Did you feel forced to resign or did your employer cause you to resign?

Yes
No

If so, how?

Did your employer make pre-employment promises about your job that they did not keep?

Yes
No

If so, briefly explain:

Do you have a written or verbal employment contract?

Yes
No

If so, describe any promises the employer broke?

Do you believe you have been harassed or discriminated against due to any of the following? If so, please select those that apply:

Race
Gender
Age
Physical or Mental Disability
Objecting to illegal acts
Sexual orientation
Marital status
Requesting or taking a Family Medical Leave

If so, briefly describe the harassment/discrimination?

What is the name and job title of the person who harassed or discriminated against you:

Did you report the harassment or discrimination to the company?

Yes
No

If yes, to whom did you report it (name and job title)?

What action, if any, did your employer take?

Have you been retaliated against for objecting to any conduct that you believe is illegal?

Yes
No

Which best describes the reason for the retaliation?

Objecting to illegal practices by your employer
Refusing to do things that you believe are illegal
Objecting to harassment/discrimination
Discussing your compensation or job conditions with others
Other

Briefly describe the illegal conduct and the retaliation:

Who retaliated against you (identify name and job title)?

Briefly describe your job duties:

Did you work over 8 hours a day?

Yes
No

If so, were you paid time and a half for overtime?

Yes
No

Are you an hourly employee?

Yes
No

If so, were you paid for all hours that you worked?

Yes
No

If so, were you given daily meal and rest periods?

Yes
No

Briefly, provide any other additional information you believe we should be aware of:

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