| Name |
|
| Address |
|
| City |
|
| State |
|
| Zip |
|
| Email |
|
| Phone |
|
|
| Employer |
|
| # of Employees |
|
| Address |
|
|
Do you have an employment contract?
|
What was the rate of pay (hourly or salary) paid by your employer?
|
What was your job title and describe your job responsibilities.
|
How often do you work more than 40 hours a week?
|
Do you receive additional compensation when you work more than 40 hours a week?; If so, how much more?
|
Do you sign-in or punch a clock at the beginning and end of the workday?
|
Do you perform job duties or attend meetings before you clock in or after you clock out?
|
Does your employer deduct from your pay for discipline or other reasons? If so, explain.
|
Were you fired or laid off? If so, on what date?
|
Do you have a new job? If so, when were you hired and how much do you make?
|
Were you demoted? If so, on what date?
|
Did you apply for a promotion that you did not receive? If so, on what date?
|
Do you believe that similarly situated colleagues of a different gender were paid more than you?
|
Did your employer refuse to restore you to your previous position when you returned from FMLA?
|
Do you have a disability? If so, describe.
|
If you have a disability, did you request an accommodation by your employer? If so, describe.
|
Were you harassed at your workplace? If so, during what time period?
|
Did you complain to your employer about the way you were treated? If so, when?
|
Did your employer retaliate against you after you complained?
|
Were you hurt on the job; if so, did you request that your employer file a claim for workers’ compensation benefits?
|
Please provide a short description of your complaint.
|
How did you hear about us?
|
|
|
