Discrimination/Retaliation/Whistleblower - 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

Race:

--Select-- Caucasian/White African-American/Black Hispanic Asian Other

U.S. Citizen?

--Select-- Yes No

Employer whom you are contacting us about:

Address of employer:

Did your employer employ over 50 employees?

--Select-- Yes No

Rate of Pay:

per --Select-- Hour Week Month Year

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

--Select-- Yes No

What is the status of the grievance?

Hire Date:

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

Current position:

Are you still employed with this employer?

--Select-- Yes No

If no, why did you leave?

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.

What was the adverse action taken by your employer? Hold down the CTRL key to select more than one.

--Select-- Termination Suspension Demotion Failure to Promote Failure to Hire Reprimand Forced to resign/retire Refusal to Reinstate Other

Please describe.

Are there any written documents outlining the terms of your employment?

--Select-- Yes No

Do you have a written contract?

--Select-- Yes No

Does the contract prevent you from being disciplined unliess it is "for cause"

--Select-- Yes No

Does the contract have a specific beginning and ending date?

--Select-- Yes No

Are you required to arbitrate employment disputes?

--Select-- Yes No

If yes, have you requested arbitration of this matter?

--Select-- Yes No

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

If not, go to next question

--Select-- Yes No

Are you a member of a Union?

--Select-- Yes No

If so, what Union?

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

--Select-- Yes No

What is the status of the grievance?

On what basis do you believe that you were discriminated against?

--Select-- Race Sex Religion Age Disability Pregnancy Handicap Whistleblower/Retaliation Veteran's Status Marital Status Filing a worker's compensation claim Taking leave for a serious medical condition Other

If other, please describe.

Do you believe that you were discriminated against based on a disability (including a history or disability or your employer's belief that you were disabled)?

--Select-- Yes No

If no, click here to skip to the next section.

Do you suffer from any disability?

--Select-- Yes No

Were you perceived by your employer to suffer from a disability?

--Select-- Yes No

Why do you believe that your employer believed that you suffered from a disability?

Do you previously suffer from any disability?

--Select-- Yes No

What is the disability from which you suffer, from which you previously suffered, or from which your employer believed you to suffer?

Did your employer know of the disability?

--Select-- Yes No

How did your employer know?

When was your employer notified?

What activities does (or did) the disability prevent you from performing in your personal or working life?

Does the disability prevent you from performing any part of your regular job duties?

--Select-- Yes No

Please describe:

Did you ever ask for any accommodation or assistance or any change in duties?

--Select-- Yes No

If so, what accomodation or assistance or change did you request?

How did your employer respond to your request for accommodation?

Do you feel that you can perform the job (either with an accommodation or without an accommodation)?

--Select-- Yes No

If you would need an accommodation or assistance, what would be required to allow you to perform the job?

Do you believe that any disciplinary action was taken against you based on your complaint to any agency, your report of illegal activity, your refusal to participate in illegal activity, or your objection to illegal activity?

--Select-- Yes No

If no, click here.

Was your employer involved in any illegal activity which you reported?

--Select-- Yes No

To whom did you report this activity?

What was the illegal activity you reported?

What statute, rule or regulation do you believe that the conduct violated?

What, if any harm, do you believe that the conduct created or could have created?

Are you employed by any governmental agency, or by a governmental contractor?

--Select-- Yes No

If so, did you report any gross mismanagement, malfeasance, gross waste of public funds, or gross neglect of duty?

--Select-- Yes No

What was the activity your reported?

To whom did you report this activity?

To whom did you report this activity?

Did you ever object to or refuse to participate in any illegal or improper action at your job?

--Select-- Yes No

What was the action?

When did you object to it, or refuse to participate in it?

Have you participated in an investigation, hearing or other inquiry conducted by any government entity?

--Select-- Yes No

In what did you participate?

What was the date of the participation?

Have you previously filed any charge of discrimination with the EEOC or other agency, or have you filed any other charge against your employer for which you believe that you were retaliated against?

--Select-- Yes No

With what agency did you file such charge?

What was the date of the filing?

What are the reasons that you believe you were discrminated or retaliated against?

Did anyone make any statements that you believe support your claims of discrimination or retaliation?

--Select-- Yes No

Who was the person or persons who made the statement or statements?

What position did the person hold at the time that he or she made the statements?

What were the statements?

Who heard these statements (if made orally)?

Were any statements made in writing?

--Select-- Yes No

On what document?

Do you have a copy of the document?

--Select-- Yes No

Do you believe that you were discriminated against or retaliated against based on any different treatment of any other person by your employer?

--Select-- Yes No

Who was treated differently than you?

How was this person(s) treated differently than you?

Why do you believe that different treatment of this person(s) shows discrimination or retaliation?

What was the reason given by your employer for the adverse action taken against you?

What do you perceive to be the "real" reason for the adverse action?

Were you paid overtime payment of time and a half your regular wage for hours worked in excess of 40 a week?

--Select-- Yes No

If not, please explain why you were not paid overtime.

Have you ever previously formally charged any employer with violation of employment law (for example, violations of overtime laws, OSHA regulations, or EEOC violations)?

--Select-- Yes No

If yes, please describe.

Have you ever sued anyone before for any reason?

--Select-- Yes No

If yes, please explain the nature of the lawsuit and the result.

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!

I do not agree I agree