Company or individual
name:
Address (if known):
If Company, # of
employees:
EVENTS
THAT CAUSED YOU TO 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]:
Has it been
more than one year since the above events
took place?
Select
Yes
No
OTHER
ATTORNEYS YOU HAVE COMMUNICATED WITH
Have you spoken
with, met with, or corresponded with any
other attorneys regarding the issue that
you wish to speak with us about?
Select
Yes
No
If yes, please
explain:
COMPLAINTS
TO EMPLOYER (Complaints to union are addressed in
another section.)
Did you complain
to your employer in writing?
Select
Yes
No
Did you complain to your
employer verbally?
Select
Yes
No
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
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)?
Select
Yes
No
If yes, have you received
a Right-to-Sue letter?
Select
Yes
No
Have you filed a complaint
with the Department of Labor Standards Enforcement
(DLSE), the Labor Commissioner)?
Select
Yes
No
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?
Select
Yes
No
If yes, how do you believe
you were retaliated against?
YOUR JOB WITH
THIS EMPLOYER
Dates
of employment: Start date:
Perfomance
Evaluations
Did you ever
receive a negative performance evaluation
from this employer?
Select
Yes
No
If yes, please explain:
Arbtitration
Agreements
Did your employer
ask you agree to arbitration, either as
part of a handbook or given to you as a
separate document?
Select
Yes
No
If yes, did you sign the
handbook or arbitration agreement?
Select
Yes
No
Termination
of Employment
Were you involuntarily
terminated (i.e., fired, laid off, etc.)?
Select
Yes
No
If yes, what was the reason
your employer gave you for the termination:
General Job
Characteristics
Please circle the
statement which best describes your job:
Work
Location
a.
Supervision
a.
Decision
Making
a.
Hours
a.
Assignments
a.
WAGE &
HOUR
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.
What
were your rates of pay, and when? (Estimates are
okay.)
What
other compensation were you paid? (Circle all
that apply): Bonuses, Commissions, Tips, Other
(specify):
If you received
tips, did management take any part of your
tips?
Select
Yes
No
What
job titles did you hold with your employer, and
when?
For each
job title you listed above, please generally describe
the duties of that job:
If at
any time you had any supervisory responsibility
with your employer, describe, and when:
If you
worked more than 8 hours per day and/or 40 hours
per week, why was this required?
Did your employer
know that you were working more than 8 hrs/day
and/or 40 hrs/week?
Select
Yes
No
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?
Select
Yes
No
If you worked more than
12 hours in a day, did you receive 2 times
your regular hourly rate?
Select
Yes
No
Did you work all 7 days
in a work week?
Select
Yes
No
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?
If your
co-workers were treated the same as you, please
provide their names, addresses, and telephone
numbers, if known:
BREAKS
AND MEAL PERIODS
EMPLOYMENT-RELATED
EXPENSES
Were you reimbursed
for work-related expenses (cell phone, uniforms,
mileage (other than commuting), travel,
supplies, etc.)?
Select
Yes
No
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?
Select
Yes
No
VACATION
PAY
If no,
why not?
DISCRIMINATION
& HARASSMENT
Do you believe
that your treatment at work was motivated
by discrimination or harassment?
Select
Yes
No
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?
Select
Yes
No
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?
Select
Yes
No
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?
Select
Yes
No
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?
Select
Yes
No
If yes, have you sought
treatment from (or been examined by) a psychiatrist,
psychologist, or other health care provider
for your emotional distress?
Select
Yes
No
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 Kesluk & Silverstein, P.C.,
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:
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:
