Name
:
Address
:
City
:
State
:
Zip
:
Phone
:
E-mail
:
Were you fired?
Select
Yes
No
If fired when?
If not fired, do you think
you are about to be fired?
Select
Yes
No
When?
Were you given a reason for being
fired/about to be fired? What reason?
Do you think it's really for a different
reason? If so what reason?
Did you quit?
Select
Yes
No
When did you quit?
Why did you quit?
Were you or are you being harassed?
Select
Yes
No
When was the last time?
What (briefly) constituted the harassment?
Why do you think you were being harassed?
Did you report the discrimination
or harassment to anyone in your company?
Select
Yes
No
Who did you report it to?
What is their position?
Are they still employed there?
Select
Yes
No
Did anyone witness the discrimination
or harassment?
Select
Yes
No
Who witnessed it?
What did they see or hear?
Are they still employed there?
Select
Yes
No
Did you report the discrimination
or harassment to any government agency?
Select
Yes
No
Which agency?
When was it reported?
Did you file a written complaint?
Select
Yes
No
Did you receive anything in writing
notifying you that you can file a lawsuit?
Select
Yes
No
When did you receive it?
Are you presently employed?
Select
Yes
No
Where are you presently employed?
How long have you been
employed?
What do you earn?
If you were fired or quit, how long
were you there?
How much were you making?
Please indicate any other facts that
you believe are important. We need to know what your
employer did to you, what reason you think they did
it which you believe it illegal, and what damage or
loss you suffered because of what they did.
