Delegal Law Offices

Family Medical Leave Act

Gender

Race:

Are you a U.S. Citizen?


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?

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?

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

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?

Was it your serious medical condition or a family member's?

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?

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

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

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

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

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

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

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

Did the employer know the reason why you took leave?

Do you have any documentation to support your claims?

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

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

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


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


Questionnaires and Labor Law Issues

Questionnaires:


Legal Issue:


Schedule an Evaluation


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