Contact the Sacramento Attorneys at York Law Firm
Toll free 800-939-1832 or Sacramento 916-643-2200

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.

* Required Field

Contact Information

* Name:

Street:

City:

State:

Zip:

Phone:

Other Phone:

* Email:

* How did you hear about us?

Yellow PagesInternet/Search EngineFindlawOther

Another attorney:

Employment Information

* 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?

TerminatedResignedStill Employed

* 7a. If you were terminated, please state the reason the employer gave you for terminating you?

* 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?

YesNo

9a. If so, on what basis? (check all that apply)

RaceGender / SexAge (over 40)Sexual HarassmentNational OriginSexual OrientationReligionPregnancyDisability / Medical ConditionMarital StatusOther

* 10. When did the last discriminatory event take place (exact date)?

* 10a. Has it been more than one year since the last event?

YesNo

11. Were discriminatory comments made about your: (check all that apply)
RaceGender / SexAge (over 40)Sexual HarassmentNational OriginSexual OrientationReligionPregnancyDisability / Medical ConditionMarital StatusOther

* 12. Were people who were (different race, the opposite sex, younger, different sexual orientation, or of a different religion) treated more favorably?

YesNo

* 13. Did you report or blow the whistle on any unlawful or fradulent conduct occurring in the workplace?

YesNo

13a. 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?

YesNo

* 16. Did you complain in writing or verbablly?

In writingVerbally

* 17. Who did you complain to?
SupervisorManagerHuman ResourcesDirectorPresidentOutside government agencyOther

Other:

18. What was the response of the employer when you complained? (check all that apply)
InvestigationRetaliationDisciplinary action against youNo ActionDemotionLow performance reviewOther

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?

This Year:
BelowMeetsExceeds
1 Year Ago:
BelowMeetsExceeds
2 Years Ago:
BelowMeetsExceeds
3 Years Ago:
BelowMeetsExceeds
4 Years Ago:
BelowMeetsExceeds
5 Years Ago:
BelowMeetsExceeds

Personal Information
* 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 medicalGeneral medicalPsychologicalPsychiatricOther CounselingNone

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

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?

YesNo

If so, what type, and how many?

* 25. Have you ever been convicted of a felony?

YesNo

* 26. Have you declared bankruptcy in the last 5 years?
YesNo

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 enter the characters into the box below.
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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.

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