Sexual Harassment - 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

Employer whom you are contacting us about:

Address of employer:

Did your employer employ:

--Select-- Fewer than 15 employees Over 15 employees Over 100 employees Over 200 employees Over 500 employees

Rate of Pay:

per --Select-- Hour Week Month Year

Hire Date:

Date(s) of the sexual harassment

Are you still employed at the place where the harassment took place?  If no, answer blue questions.  If yes, answer red question

--Select-- Yes No

If no, why did you leave?

Are you re-employed?

--Select-- Yes No

If so, where?

Current position (if still employed)

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 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?

Who was the person that harassed you?

Was that person --Select-- Male Female ?

Was that person a supervisory employee?

--Select-- Yes No

Was that person your supervisor?

--Select-- Yes No

What position did that person hold in the company?

Did the harasser ever offer you any benefit?

--Select-- Yes No

If so, what was the benefit?

Did the harasser ever threaten any adverse action if you did not submit to advances or improper conduct?

--Select-- Yes No

If so, what was the threat?

Did the harasser ever touch you inappropriately on any part of your body?

--Select-- Yes No

On what part of your body?

Was the touching with your consent?

--Select-- Yes No

Did you ever communicate to the harasser that you did not want to continue any relationship with the harasser?

--Select-- Yes No

Did you ever engage in sexual relations with the harasser?

--Select-- Yes No

On what part of your body?

Was the sexual contact consensual at the time?

--Select-- Yes No

When did that sexual contact take place?

Did the harasser ever take any other action which you believed to be harassing?

--Select-- Yes No

If so, what was that action?

Did you ever notify your harasser that you wished that he or she would stop the harassment?

--Select-- Yes No

Did your employer have a sexual harassment policy?

--Select-- Yes No

Did you report the harassment?

--Select-- Yes No

To whom did you report the harassment?

How did you report the harassment?

Was the report --Select-- Verbal In writing ?

When did you report it?

Did you report the harassment in a manner consistent with the sexual harassment policy?

--Select-- Yes No

Was the incident ever investigated?

--Select-- Yes No

If so, was any action taken as a result of the investigation?

Was any discipline issued to anyone?

--Select-- Yes No

Were you ever disciplined as a result of the investigation?

--Select-- Yes No

What was the discipline issued and to whom was it issued?

Did the harassment stop after the investigation and/or discipline?

--Select-- Yes No

How has the harassment affected you personally?

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 yes, please explain.

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 no, explain why you were not paid overtime?

What person or company did you charge with violating employment laws or regulations?

What employment laws or regulations did you contend that the company violated?

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

Have you ever sued anyone before for any reason?

--Select-- Yes No

If so, explain 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