Delegal Law Offices

Discrimination/ Retaliation/Whistleblower Questionnaire

Gender

Race:


Employer about whom you are contacting us:

Address of employer:

Did your employer employ over 50 employees?

Rate of Pay

per:

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

Hire Date:

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

Current Position:

Are you still employed with this employer?

Were you issued any employment evaluations?

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

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

What was the adverse action taken by your employer? Hold down Ctrl or Command to select more than one.

Please describe

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

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

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

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)?

Do you suffer from any disability?

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

Did you previously suffer from any disability?

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 this disability?

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?

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

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


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?

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

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

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

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

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?

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

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

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

What was the reason given by your employer 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?

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

Have you ever sued anyone before for any reason?


How did you learn of our firm?


Additional Information

Please provide any additional information about yourself or the case which would help the attorneys understand you 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 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 obligated to schedule a meeting 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 THIS FORM!

I agree with the terms of this form


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Recent Awards: Tad Delegal Presented the 2017 Non-Compete Seminar portion of the Florida Bar's Certification Review Course

2016 Florida Trend Legal Elite
2015 904 Magazine’s Legal Elite
2015 U.S. News & World Report Law Firm of the Year