Family Medical Leave Act - 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

If so, were those 50 employees employed within an 80-mile radius?

--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?

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.

Have you worked for this company for at least 1 year?

--Select-- Yes No

Were you disciplined or refused a promotion as a result of your taking leave due to yours or your family member's serious medical condition?

--Select-- Yes No

If so, what was the medical condition?

Was it your serious medical condition or a family member?

--Select-- Mine Family Member's

If a family member, what is the relationship of this person to you?

How long were you on leave?

How many days of work did you miss within the previous year (or the company's fiscal year) for leave purposes?

Were you disciplined or refused a promotion as the result of your taking leave?

--Select-- Yes No

What was the specific action taken against you which you believe to have been retaliatory? Hold down the CTRL key and click on all that apply.

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

Please describe other.

Did you lose any benefits, pay or status upon your return from leave?

--Select-- Yes No

If yes, please explain lost benefits, pay or status.

Were any insurance benefits cut off while you were on leave?

--Select-- Yes No

Please explain loss of insurance.

Were you ever provided any Family Medical Leave Act forms by your employer?

--Select-- Yes No

If so, what information did your employer request in those forms?

Did your employer ever request a medical certification or medical explanation of the condition which caused you to take leave?

--Select-- Yes No

If so, did you provide such medical certification or explanation?

--Select-- Yes No

If you did not provide the medical certification or explanation, explain why you did not do so.

Did you provide any doctor's note or other doctor's documentation to your employer?

--Select-- Yes No

If yes, name the physician.

Did your employer ever classify the leave you took as "Family Medical Leave"?

--Select-- Yes No

Did you ever request that it be considered "Family Medical Leave"?

--Select-- Yes No

Did the employer know the reason why you took leave?

--Select-- Yes No

If yes, how did the employer learn of the reasons you took the leave?

Do you have any documentation to support your claims?

--Select-- Yes No

If so, please describe.

Did any person make any statement which led you to believe that your employer had the intent to discriminate against you?

--Select-- Yes No

Did differing treatment of any other employees lead you to believe that you were being discriminated against?

--Select-- Yes No

If so, please describe.

Please list any witnesses who you believe may be able to support your claim.

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