* 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
* 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? 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)
* 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
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? 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?
This Year: Below Meets Exceeds
1 Year Ago: Below Meets Exceeds
2 Year Ago: Below Meets Exceeds
3 Year Ago: Below Meets Exceeds
4 Year Ago: Below Meets Exceeds
5 Year Ago: Below Meets Exceeds
* 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.