Name:* Social Sec. No. Home Phone: Cell Phone: Address: City/ St / Zip: Email Address:* Date of Birth: Previous Names or Aliases Name: Dates Used: Name: Dates Used: Your Immediate Family Spouse / Domestic Partner: Are you married or registered as Domestic Partners with the California Secretary of State? Children: Source How did you hear about us? Prior Lawsuits / Arbitrations Have you ever filed any lawsuits in the past? If yes, what type, against whom, and when? (Attach additional sheets if necessary.) Bankruptcies Have you filed for bankruptcy within the last ten years? If yes, what year? Where (city/state)? Are you currently considering filing for bankruptcy? Criminal Convictions Have you ever been convicted of a felony? If yes, what were you convicted of and when? Have you ever been convicted of a misdemeanor? If yes, what were you convicted of and when? Have you ever been charged with a crime for which you have not been convicted? If yes, what were you charged with and when? Have you ever been convicted of a misdemeanor? If yes, what were you convicted of and when? Have you ever been charged with a crime for which you have not been convicted? If yes, what were you charged with and when? Workers' Compensation Have you filed a workers' compensation claim? If yes, what is the status? What is the highest level of formal education you have obtained? What specialized training, if any, have you had for your job? What licenses, certificates, or special qualifications, if any, do you hold for your job? Prior Employment Have you ever been involuntarily terminated from a job? If yes, what was the employer's name, the date of termination, and the reason given for termination? Public Information About You Do you have a website? If yes, what is the website address? Do you have a webpage on Facebook, MySpace, or any other social, professional, networking, dating, or public access website? If yes, please list each such website, its web address, and the dates when you have had a page on that site: PARTIES AGAINST WHOM YOU SEEK LEGAL ACTION Company or individual name: Address (if known): If Company, # of employees: PARTIES AGAINST WHOM YOU SEEK LEGAL ACTION Describe what happened at your place of employment that caused you to seek legal action. Include any and all documents which support your allegations. Include dates of when these events took place. Attach additional sheets if necessary [limit 2 pages of narrative]: File Has it been more than one year since the above events took place? PARTIES AGAINST WHOM YOU SEEK LEGAL ACTION Have you spoken with, met with, or corresponded with any other attorneys regarding the issue that you wish to speak with us about? If yes, please explain: COMPLAINTS TO EMPLOYER Did you complain to your employer in writing? Did you complain to your employer verbally? If you complained either verbally or in writing, to whom did you complain (i.e., manager, president, director, supervisor, etc.)? If you complained, what did you complain about? For each complaint, what was your employer's response to your complaint (i.e., investigated, did nothing, punished you, etc.)? COMPLAINTS TO UNION Are/were you a member of a union for this job? If yes, which union? If you are/were a member of a union, did you file a union grievance about this matter? If you filed a union grievance, what is the status of that grievance? COMPLAINTS TO GOVERNMENTAL AGENCIES Have you filed a complaint with the Department of Fair Employment and Housing (DFEH) or the Equal Employment Opportunity Commission (EEOC)? If yes, have you received a Right-to-Sue letter? Have you filed a complaint with the Department of Labor Standards Enforcement (DLSE), the Labor Commissioner)? If yes, what is the status? RETALIATION FOR COMPLAINING Do you believe that you were retaliated against for complaining about discrimination or harassment or other illegal treatment, or for complaining about some illegal activity at the workplace? If yes, how do you believe you were retaliated against? Your most recent job title with above employer: What was your most recent rate of pay with this employer? Dates of Employment Start date: Exact End date: YOUR JOB WITH THIS EMPLOYER Did you ever receive a negative performance evaluation from this employer? If yes, please explain: Performance Evaluations Did your employer ask you agree to arbitration, either as part of a handbook or given to you as a separate document? If yes, did you sign the handbook or arbitration agreement? Termination of Employment Were you involuntarily terminated (i.e., fired, laid off, etc.)? If yes, what was the reason your employer gave you for the termination: General Job Characteristics Please select the statement which best describes your job: Work Location I always worked at my employer's place of business. I worked most of the time outside the office. I could work wherever I wanted. other Supervision I was rarely supervised. I was closely supervised part of the time. I was closely supervised all of the time. other Decision Making I could make major decisions affecting the company without checking with anyone. Sometimes I could make major decisions without any other authority. Any major decision had to be cleared with my supervisors. other Hours I had set work hours which were monitored. I set the work hours and worked as long as it took to get the job done. other Assignments I decided what I had to do, and then did it. I was given the job assignment, and it was my job to figure out how to do it. I received detailed specifications of the job, but I could do the job in any way I saw fit. My job assignments were specific, and I followed established procedures in doing them. I did what I was instructed to do. other WAGE & HOUR (MINIMUM WAGE, OVERTIME, MISCLASSIFIED AS EXEMPT, ETC.) What were your usual working hours? (Start and end time, for example, 8:00 am. – 6:00 pm). Please state the hours you actually usually worked, not just what you were scheduled for. Monday: Tuesday: Wednesday: Thursday: Friday: Saturday: Sunday: What were your rates of pay, and when? (Estimates are okay.) From to $ Hourly / Daily / Monthly / Yearly, Etc. From to $ Hourly / Daily / Monthly / Yearly, Etc. What other compensation were you paid? (Include all that apply): Bonuses, Commissions, Tips, Other (specify): If you received tips, did management take any part of your tips? Date (Start - End) Job Title Job Date (Start - End) For each job title you listed above, please generally describe the duties of that job: Job Title Dutiese Job Title Dutiese If at any time you had any supervisory responsibility with your employer, describe, and when: Date (Start - End) Supervisory Duties Date Supervisory Duties If you worked more than 8 hours per day and/or 40 hours per week, why was this required? Were you a) non-exempt (eligible for overtime pay under the law), or b) exempt (not eligible for overtime pay)? Did your employer know that you were working more than 8 hrs/day and/or 40 hrs/week? If yes, how did your employer know? How many days per week, on average, did you work more than 8 hours per day? How many weeks per year, on average, did you work more than 40 hours per week? If you worked more than 8 hours per day and/or 40 hours per work, did you receive 1.5 times your regular hourly rate? If you worked more than 12 hours in a day, did you receive 2 times your regular hourly rate? Did you work all 7 days in a work week? What conversations, if any, did you have with your employer regarding working hours? What documents, if any, exist that can help us prove your hours worked? How many of your co-workers were treated the same way as you? If your co-workers were treated the same as you, please provide their names, addresses, and telephone numbers, if known: BREAKS AND MEAL PERIODS Did your employer allow you to take a 10-minute break in the morning? Did your employer allow you to take a 10-minute break in the afternoon? Did you employer ever refuse your request to take a break? Did your employer allow you to take a meal break without interruption? If yes, for how long each day? If yes, after how many hours of work? If yes, were you allowed to leave work during your meal break? If yes, were you completely relieved of job duties during your breaks? EMPLOYMENT-RELATED EXPENSES Were you reimbursed for work-related expenses (cell phone, uniforms, mileage (other than commuting), travel, supplies, etc.)? If not, state the type and amount of the work-related expenses you were not reimbursed for: Did your employer deduct money from your pay for broken/lost/stolen merchandise? VACATION PAY How many days per year of paid vacation did your employer provide? If you no longer work for this employer, were you paid for unused vacation? If no, why not? DISCRIMINATION & HARASSMENT Do you believe that your treatment at work was motivated by discrimination or harassment? If yes, on what basis (i.e., race, age [over 40], national origin, sexual orientation, religion, disability, marital status, pregnancy, gender, sexual harassment, etc.)? Why do you believe your treatment at work was motivated by discrimination or harassment? Were people who were (younger, opposite sex, other race, not disabled, not homosexual, of a different religion, etc.) treated more favorably? If yes, briefly describe the basis (younger, not disabled, not homosexual, different religion, etc.) and the different treatment: WITNESSES & EVIDENCE Do you have any witnesses or documents to help you prove your claims? If yes, describe and include witness contact information, including name, address if known, telephone and/or email if known, their position at the company, and whether or not they are currently part of your employer's management: List the managers / owners responsible for your wages, hours, and working conditions. EFFORTS TO SEEK NEW EMPLOYMENT If you are no longer working for the company above, have you made efforts to find new employment? If yes, what efforts have you made to find new employment? EMOTIONAL DISTRESS If you feel that you were terminated, forced to quit, or discriminated against or harassed, have you suffered emotional distress as a result? If yes, have you sought treatment from (or been examined by) a psychiatrist, psychologist, or other health care provider for your emotional distress? If yes, who have you been treated or examined by for the emotional distress, and when? PLEASE READ CAREFULLY AND SIGN BELOW I understand that I have provided the foregoing information solely for the purpose of having my case reviewed. I understand that the Law Offices of Kesluk, Silverstein & Jacob, has made no decision whether to take my case, and is under no obligation to do so. I understand that submission of this information does not create an attorney-client relationship, and that if and only if my case is accepted, a written Attorney-Client Fee Agreement will be provided. Please bear in mind that, if you have time deadlines (or statutes of limitations) that are quickly approaching, we cannot guarantee that we will respond in time for us to assist you in filing a lawsuit or administrative agency complaint. You should take immediate action to avoid missing any such deadlines. You may fax your questionnaire to (310) 273-6137. Or, mail it to: Law Offices of Kesluk, Silverstein & Jacob 9255 Sunset Blvd., Ste. 411 Los Angeles, CA 90069 I certify that the information I have provided in this questionnaire and in any attached documents is true to the best of my knowledge and belief. date:* Signature:* If you have questions about this form, please contact a Los Angeles labor attorney at our law firm to assist you.