Northern California Call
Toll Free 800-939-1832

We represent clients throughout Sacramento and Fairfield as well as the entire Bay Area, including Berkeley, San Francisco, Burlingame, Alameda County, Daly City, Fremont, Oakland, San Mateo, and Redwood City.

Attorney Wendy C. York

Wendy C. York, Attorney

Potential Employment Client Questionnaire

Please bear in mind, that if you have time deadlines (or statute of limitations) that are quickly approaching, we cannot guarantee that we will respond in time for us to assist you in filing a lawsuit. You should take immediate action.

* Name:
* Street:
* City:
* State: * Zip:
* Phone:
Other Phone:
* Email:
* How did you hear about us?
Yellow Pages
Internet/Search Engine
Findlaw
Other
Another attorney:
* 1. Name of employer you wish to seek legal action against:
* 2. Address of employer:
* 3. Approximate number of employees that are employed in California?
* 4. Your most current position:
* 5. Your current rate of pay and estimated yearly income:
* 6. Number of years you were employed with employer
* 7. Were you terminated, did you resign, or are you still employed?
Terminated
Resigned
Still Employed
* 8. If you were terminated or resigned state the date of your termination/resignation?
* 9. Do you believe that your treatment at work was motivated by discrimination?
Yes   No
9a. If so, on what basis? (check all that apply)
Race
Gender / Sex
Age (over 40)
Sexual Harassment
National Origin
Sexual Orientation
Religion
Pregnancy
Disability / Medical Condition
Marital Status
Other
* 10. When did the last discriminatory event take place (exact date)?
10a. Has it been more than one year since the last event?
Yes   No
11. Were discriminatory comments made about your: (check all that apply)
Race
Gender / Sex
Age (over 40)
Sexual Harassment
National Origin
Sexual Orientation
Religion
Pregnancy
Disability / Medical Condition
Marital Status
Other
12. Were people who were (different race, the opposite sex, younger, different sexual orientation, or of a different religion) treated more favorably?
Yes   No
* 13. Did you report or blow the whistle on any unlawful or fradulent conduct occurring in the workplace?
Yes   No
If so, please provide a brief description of the details:
14. Do you believe that you were retaliated against for complaining about discrimination or for complaining about some unlawful activity at the workplace? If so, please provide details (exactly, what did you complain about)?
* 15. Did you complain about discrimination or retaliation?
Yes   No
* 16. Did you complain in writing or verbablly?
In writing   Verbally
* 17. Who did you complain to?
Supervisor
Manager
Human Resources
Director
President
Outside government agency
Other:
18. What was the response of the employer when you complained? (check all that apply)
Investigation
Retaliation
Disciplinary action against you
No Action
Demotion
Low performance review
Other:
19. Do you have any witnesses or documents that help prove your claim? If so, describe:
* 20. Please check the description that would best describe your performance evaluations for the last five years?
Expectations
Below    Meets   Exceeds
This Year:
1 Year Ago:
2 Years Ago:
3 Years Ago:
4 Years Ago:
5 Years Ago:  
* 21. Have you recently had to seek any kind of outside medical assistance or consultation as a result of work-related stress or problems at work? (check all that apply)
Emergency medical
General medical
Psychological
Psychiatric
Other Counseling
None
21a. If you have sought outside medical assistance or consultation please describe the circumstances (e.g., anxiety, depression, ulcers, high blood pressure, chest pain, counseling, etc.)
22. Have you filed a complaint with any outside governmental agency? (check all that apply)
Department of Fair Employment & Housing (DFEH)
Equal Employment Oppoirtunity Commission (EEOC)
Other
23. If you have filed a complain with an outside agency, what is the status of your filing (i.e., under investigation, right-to-sue letter issued, etc.)?
24. Have you filed any lawsuits in the past?
Yes   No
If so, what type, and how many?
* 25. Have you ever been convicted of a felony?
Yes   No
* 26. Have you declared bankruptcy in the last 5 years?
Yes   No
27. Please use the following space to describe any other events at your place of employment (that have not been discussed above) that caused you to seek legal actions. Please provide dates when discussing employer conduct.


Please bear in mind, that if you have time deadlines (or statute of limitations) that are quickly approaching, we cannot guarantee that we will respond in time for us to assist you in filing a lawsuit. You should take immediate action.