Civil Service - Public Sector - Government Employment Questionnaire

Name:

Address (include city, state and zip):

Telephone:

- Home

- Work

- Cell

Email address:

Confirm email:

Date of birth (MM/DD/YYYY):

Place of birth:

Gender:

--Select-- Male Female

U.S. Citizen?

--Select-- Yes No

I am employed by:

--Select-- State of Florida City of Jacksonville Duval County School Board Federal Government Other

If other, please specify:

Agency or Division by which I am employed:

Rate of Pay:

per --Select-- Hour Week Month Year

Hire Date:

Date of disciplinary action or other adverse action? (if applicable)

Current Position (if still employed)?

Last position held:

Are you still employed with this employer?

--Select-- Yes No

If no, why did you leave?

Hiring Circumstances (including who hired you and how you learned about this job)

Were you issued any employment evaluations?

--Select-- Yes No

If yes, how well were you evaluated?

Did you receive any other awards or other evaluations of your employment?

--Select-- Yes No

Please describe the award or evaluation with the date you received it.

Were you ever disciplined in the past prior to the event about which you are currently complaining?

--Select-- Yes No

Please describe the discipline with the date you received it.

Are there any witnesses or other co-workers who can testify to your claims?

--Select-- Yes No

Witness 1 Name

Witness 1 Expected Testimony

Witness 2 Name

Witness 2 Expected Testimony

Witness 3 Name

Witness 3 Expected Testimony

Was your position covered by Union contract (even if you are not a union member)?

--Select-- Yes No

Are you a member of a Union?

--Select-- Yes No

If so, which Union?

Have you initiated a Union grievance regarding the matter you are describing in this questionnaire?

--Select-- Yes No

If yes, have you requested arbitration of this matter?

Have you ever been arrested for a crime?

--Select-- Yes No

First Incident

Type of Crime

City, State

Date of Arrest

Were you convicted?
--Select-- Yes No

What was the sentence?

Second Incident

Type of Crime

City, State

Date of Arrest

Were you convicted?
--Select-- Yes No

What was the sentence?

Third Incident

Type of Crime

City, State

Date of Arrest

Were you convicted?
--Select-- Yes No

What was the sentence?

What is the nature of this case?

--Select-- Failure to Hire Denial of Promotion Disciplinary Action Veteran's Preference Matter

Have you obtained vested status with the employer? (Completed probation)

--Select-- Yes No

Are you a permanent employee (as opposed to a temporary employee)?

--Select-- Yes No

Discipline

Does this involve a disciplinary matter?

--Select-- Yes No

If no, click here to skip to the next section. If yes, please complete remining questions in this section.

What are the allegations against you?

What disciplinary action has been taken against you, or is proposed to be taken?
--Select-- Termination/Filing Demotion Suspension Reprimand Other Disciplinary Action

Do you believe that the allegations are untrue?
--Select-- Yes No

Do you believe that the discipline is unnecessarily harsh?
--Select-- Yes No

Have you received a formal notice of disciplinary action?
--Select-- Yes No

Date received

Failure to Hire or Promote

Are you alleging a failure to hire or failure to promote, or are claiming a denial of hiring or promotion based on veteran's preference?

--Select-- Yes No

If no, click here to skip to the next section. If yes, please complete remining questions in this section.

When did you apply for the position?

For what position did you apply?

Was a test administered?
--Select-- Yes No

If so, how well did you perform on the test?

Were you provided any reason that you were not hired/promoted?
--Select-- Yes No

If yes, what reason was provided to you?

What rules, regulations, or policies support your claim that you should have been hired/promoted?

Why do you believe that you should have been hired/promoted for the position?

When were you first notified that you were not hired/promoted for the position?

Veteran's Preference

Are you claiming a violation of veteran's preference?ference

--Select-- Yes No

If yes, please complete remining questions in this section.

Of what war or conflict are you a veteran?

Have you received a DD-214?
--Select-- Yes No

When?

Have you previously been hired or promoted by any public agency since receiving your last DD-214?
--Select-- Yes No

When and with what agency?

Have you contacted the Department of Veterans Affairs?
--Select-- Yes No

When?

What action did you take with the Department of Veteran's Affairs?

What response have you received?

Have you filed a notice of appeal?
--Select-- Yes No

If so, when was it filed?

If so, with what agency or person?

Have you filed a grievance?
--Select-- Yes No

If so, when was it filed?

If so, with what agency or person?

Do you believe that the action of which you complain is related to any discrimination based on:

--Select-- Race Religion Gender National Origin Marital Status Pregnancy Age Disability Previous filing of discrimination complaint Veteran's Status Whistleblowing

Why do you believe the action involves discrimination on such basis or bases?

How did you learn of our firm?

--Select-- Attorney Yellow Pages Newspaper Article Web Search Other

If an attorney referred you, what is the name of the attorney or firm?

If another person referred you, what is that person's name?

Additional Information

Please provide any additional information about yourself or the case which would help the attorneys understand your potential case or explain your answers to the above questions.

Scheduling

We will contact you by phone or email unless you request some alternate means of communication.

PLEASE READ THE FOLLOWING STATEMENTS AND INDICATE YOUR ACCEPTANCE OF THESE TERMS PRIOR TO SUBMITTING THIS FORM.

I have prepared the answers to these questions and to the best of my ability.

I understand that the submission of this form does not create any obligation for me or for any attorney at Delegal Law Offices.

I further understand that submission of this form does not create an attorney-client relationship and that the lawyer is not obliged to schedule a consultation with me.

I understand and agree that Delegal Law Offices, P.A., will have no duty to keep confidential the information that I am transmitting to the law firm through this questionnaire.

YOU MUST AGREE OR YOU CANNOT SUBMIT THE FORM!

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