Intake Questionnaire

Employment Discrimination / Sexual Harassment / Retaliation / Civil Rights / Wrongful Termination / Whistleblower

NOTICE: The information contained in this questionnaire is CONFIDENTIAL and will be used by the law firm of Charlson Bredehoft Cohen, Brown & Nadelhaft, P.C. to assist in determining whether the firm can help you with your case. No attorney-client relationship is established by the provision of confidential information, and no attorney-client relationship will be established until such time as you and we sign a written agreement establishing an attorney-client relationship. It is understood that the law firm of Charlson Bredehoft Cohen, Brown & Nadelhaft, P.C. will rely on the fact that the information contained herein is truthful, accurate and complete unless noted otherwise.

1. Is there a known deadline that you are facing? (Explain)

Today's Date

2. Contact Information

First name*

Middle name

Last name*

Your email*

Phone number (Cell)*

Phone number (Office)

Phone number (Home)

I prefer to be contacted by phone
By cell phoneAt homeAt office

Best time to call?

Street address

City

State

Zip code

County

Date of birth

Gender
MaleFemaleOther

Race

How were you referred to/how did you learn of our office?

Which, if any, attorney in our office were you referred to?

3. Who is your complaint against?

Name of company/employer

Address where you work(ed)

Business telephone

Type of business

Does the company have locations elsewhere?
YesNo

Company size/number of employees
less than 1515-5051-100101-200201-500500+

Name(s) of Individual(s)

Address

Telephone

4. Explain how you fit into the organization

Your date of hire:

Your date of demotion or termination (if applicable):

Department/Division you work(ed) in:

Your position title:

Date you were assigned to this position:

Your wage/salary:

Benefits:

Your immediate supervisor's name:

Your immediate supervisor position's title:

5. DO YOU HAVE AN EMPLOYMENT AGREEMENT, STOCK OPTION, COVENANT NOT TO COMPETE, NON-SOLICITATION AGREEMENT, or ANY OTHER AGREEMENT or CONTRACT WITH YOUR EMPLOYER? If yes, please contact us for instructions as to how to submit a copy (unless they do not relate, but please indicate the name or description and date of each so we are aware of its existence).
YesNo

6. HAVE YOU SIGNED ANY SEVERANCE AGREEMENT or SEPARATION PACKAGE WITH YOUR EMPLOYER? (If yes, please contact us for instructions as to how to submit a copy.)
YesNo

7. HAVE YOU BEEN PRESENTED WITH ANY TYPE of SEVERANCE / SEPARATION AGREEMENT or PACKAGE BUT HAVE NOT YET SIGNED? (If yes, please contact us for instructions as to how to submit a copy, along with any questions or concerns relating to the Agreement)
YesNo

8. DO YOU BELIEVE YOU WERE DISCRIMINATED AGAINST/TREATED UNFAIRLY BASED ON: (Check all that apply)
Sexual HarassmentRaceColorSexNational OriginAgeReligionDisabilityMarital StatusSexual OrientationRetaliationFamily Medical Leave ActEqual Pay ActBecause I brought to the attention of my employer illegal actsBecause I refused to engage in illegal actsOther (Please Explain)

If other selected, please explain:

9. EXPLAIN WHAT ACTION WAS TAKEN AGAINST YOU THAT YOU BELIEVE WAS DISCRIMINATORY OR UNLAWFUL: (Tell us who, what, when, where and why. Feel free to attach additional documents.)

10. WHY DO YOU BELIEVE WHAT HAPPENED IS DISCRIMINATION, RETALIATION, OR OTHERWISE, ILLEGAL? (As you marked in 8.)

11. WHAT REASON(S), IF ANY, WAS GIVEN FOR THE ACTION TAKEN AGAINST YOU ? (Tell us who, what, when, where and why.)

12. WHAT IS THE EMPLOYER'S NORMAL POLICY/PRACTICE IN A SITUATION SUCH AS YOURS, IF APPLICABLE?

13. Is the policy in writing? If yes, can you provide us a copy?
Yes, I can provide a copyYes, but I can not provide a copyNo

14. HAVE OTHERS BEEN TREATED DIFFERENTLY THAN YOU FOR THE SAME CONDUCT ? (If yes, please tell us who, what, when, where and why.)
YesNo
If yes, please tell us who, what, where, when and why:

15. DID YOU REPORT THE ACTION TO ANYONE AND, IF SO, TO WHOM AND WHEN. PLEASE ALSO DESCRIBE WHAT INVESTIGATION, IF ANY, AND WHAT ACTION, IF ANY, WAS TAKEN AS A RESULT OF YOUR COMPLAINT .

16. DOES YOUR EMPLOYER HAVE A GRIEVANCE/COMPLAINT POLICY/PROCEDURE THAT MAY APPLY? IF SO, PLEASE DESCRIBE AND IF POSSIBLE, ATTACH THE POLICY.

17. IF THERE IS A GRIEVANCE/COMPLAINT PROCEDURE OR POLICY, DID YOU FOLLOW IT? PLEASE DESCRIBE WHAT YOU DID. IF NOT, PLEASE EXPLAIN FULLY WHY YOU DID NOT FOLLOW IT.
YesNo
Explain:

18. HOW, IF AT ALL, DID YOUR WORK ENVIRONMENT OR TERMS OF EMPLOYMENT CHANGE FOLLOWING YOUR COMPLAINT ?

19. DO YOU HAVE ANY WITNESSES ? (We will not contact anyone until we have spoken to you and obtained your consent.)

Witness 1 /Name:

Witness 1 / Relevant Relationship:

Witness 1 / Telephone No - Email Address:

Witness 2 /Name:

Witness 2 / Relevant Relationship:

Witness 2 / Telephone No - Email Address:

Witness 3 /Name:

Witness 3 / Relevant Relationship:

Witness 3 / Telephone No - Email Address:

20. IF YOU WERE TERMINATED, HAVE YOU BECOME RE-EMPLOYED? IF SO, HOW MUCH MORE OR LESS ARE YOU EARNING TODAY IN RELATIONSHIP TO WHAT YOU EARNED AT THE POINT OF TERMINATION ? Please include a detailed and itemized comparison of salary, commissions, bonuses, and all benefits between your previous position (that from which you were terminated, etc.) and your new position.

21. HOW DID THESE EVENTS IMPACT YOU, AND DO THEY CONTINUE TO AFFECT YOU TODAY ?

22. HAVE YOU EVER FILED ANY TYPE OF DISCRIMINATION SEXUAL HARASSMENT, RETALIATION, OR WRONGFUL TERMINATION CLAIM OR COMPLAINT BEFORE? (IF SO, PLEASE PROVIDE A DETAILED DESCRIPTION OF EACH CLAIM AND HOW IT WAS RESOLVED).

23. IS THERE ANYTHING ELSE YOU BELIEVE MAY BE RELEVANT, POSITIVE OR NEGATIVE, THAT YOU BELIEVE WE SHOULD KNOW IN CONSIDERING OR EVALUATING YOUR CLAIM, OR IN REPRESENTING YOU?

I agree that the above facts are true to the best of my knowledge and belief.