| 1.
Name |
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| 2. Address: |
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| 3. Unit/Apt #: |
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| 4. City |
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| 5. State: |
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| 6. Zip Code: |
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| 7. Home Phone: |
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| 8. Mobile Phone: |
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| 9. Fax Number(s): |
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| 10. Email
Address: |
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| 11. Ethnic
Background: |
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| 12. Religion: |
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| 13. Sex/Gender: |
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| 14. Sexual
preference (orientation): |
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| 15. Pregnancy
(current or past): |
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| 16. Age (Date of
Birth): |
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| 17.
Disabilities/Medical Conditions (if any): |
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| 18. Marital
Status: |
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19. Prior Lawsuits including claims of personal
injuries, car accident claims, wrongful terminations and
bankruptcies, evictions, workers compensation, etc.:
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20. Name/Identify of Employer where harassment or
other wrongful conduct occurred (including whether
employer is current, former or prospective):
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21. Your title and duties with the employer:
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22. Salary, wages and/or benefits you received from
the employer:
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23. Type of business the employer engages in:
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24. How many people work for the employer (employees
and independent contractors):
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25. Employment status (employed, unemployed,
suspended, fired, laid off, disability or medical leave,
denied employment, denied promotion, terminated,
etc.):
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26. Length of employment (How long you were employed
with the employer where the termination or other
misconduct occurred?):
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27. Employer’s Anti-Harassment (does the employer
have a written or oral policy against sexual harassment?
Employee Handbook?):
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28. Names of employees who committed the harassment
or other wrongful conduct (decision makers and
harassers):
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29. Date(s) harassment or other wrongful conduct took
place:
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30. Motive behind the harassment or other wrongful
conduct (sexual, racial, national origin, disability,
medical leave, religion, wages/overtime, marital status,
whistleblower):
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31. Form of the harassment or other wrongful conduct
(requests/demands for sexual favors, termination, lay
off, slurs, jokes, touching, yelling, physical abuse,
micromanagement, undeserved criticism and discipline,
denied promotions, appraisals and evaluations of poor
performance, demotion, suspension, counseling,
discipline, slander, libel, false statements, removal of
duties, reassignments, relocations and transfers,
invasion of your privacy or non-work related
conduct):
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32. Any reasons and excuses the employer or harasser
gave for the harassment or other wrongful conduct
(statements in termination letter, exit interview,
appraisals, evaluations, oral statements at time of
harassment, termination or other wrongful conduct):
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33. Harasser’s/wrongdoer’s
characteristics/description (age, race, ethnic
background, religion, disabilities/medical conditions,
sexual preference (orientation), pregnancy (current or
past), marital status, title, job duties, years with
company):
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34. Personal Relationship with harasser (did you ever
date or engage in a romantic or sexual relationship with
the harasser or the harasser’s close relative):
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35. Identify the witnesses to the harassment or other
wrongful conduct (names, phone numbers, addresses):
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36. Employer's Litigation History (Has the employer
and/or harasser ever been sued before for harassment or
other wrongful conduct against an employee? If so, who
were the plaintiffs? Who were the witnesses?):
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37. Internal complaints (Did you object to the
harassment? Did you complain about it? Did you inform
your employer, supervisor, union representative or human
resources of the harassment? If so, provide the date,
and manner in which such a complaint was made (oral or
in writing)):
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38. Investigation by the employer (did the employer
conduct an investigation to determine whether the
harassment or other wrongful conduct occurred? If so,
who conducted the investigation (title)? When was it
conducted? Who was interviewed? Was the investigation
conducted confidentially? Was the investigation
concluded? What were the conclusions of the
investigation? Was anyone disciplined as a result of the
investigation? How?):
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39. Retaliation/Reprisals/Punishments (Were you
punished for complaining or objecting to the
harassment/wrongful conduct? Did harassment increase or
become more severe after you complained or objected? If
so, when? What changed after you complained or
objected?):
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40. Desired compensation and other remedies (what you
want the employer and harasser(s) to pay you as
compensation for the wrongful conduct you endured? What
you believe would be a fair resolution of your claim of
harassment?):
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41. Are you (or were you) represented by an attorney
with respect to the claim you have contacted us about?
If so, please identify that attorney and why you are
seeking an advice from another attorney.:
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42. Did your employer/supervisor/manager, treat other
employees differently than you were treated? (Were you
singled out?):
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43. Have you applied for unemployment benefits? (If
so, did your former employer oppose your receipt of such
benefits? What happened?):
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44. Additional Information (Please provide us with
any additional facts you believe are important):
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45. How did you find us:
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