What's your name?
*
Phone Number
*
Email Address
*
What is your mailing address?
Preferred Language
English
Spanish
Briefly describe your employment problem
Type of employment case
Wage and Hour Violations (no rest breaks, no meal breaks, no minimum wage, no overtime, etc.)
Discrimination (race, age, gender, religion, disability, medical condition, pregnancy, sexual orientation)
Harassment (sexual harassment, hostile work environment, harassment based on discrimination)
Retaliation (for getting injured at work, for filing worker's comp, reporting an unsafe workplace, etc.)
Worker's Compensation (injured at work)
Other
Are you getting your rest breaks?
Yes
No
Sometimes
Are you getting your meal breaks?
Yes
No
Sometimes
Are you getting paid overtime?
Yes
No
Sometimes
Have you worked off the clock?
Yes
No
How often did you work off the clock?
How many times has the violation happened?
1-10 times
11-50 times
50 + times
N/A
Did you report these problems to the company/supervisor in writing, verbally, both, or neither?
Reported verbally
Reported in writing
Both: written and verbally
Neither
Other
Can you provide documentation of the writing?
Yes
No
What is the basis of the discrimination?
Race
Age
Gender
Religion
Disability
Medical Condition
Pregnancy
Sexual Orientation
Military Status
Other
When was the last time the discrimination happened?
Did you report these problems to the company/supervisor in writing, verbally, both, or neither?
Reported verbally
Reported in writing
Both: written and verbally
Neither
Other
Can you provide documentation of the writing?
Yes
No
Is the offender another employee or someone above you (e.g., owner, manager, supervisor)?
Another employee
Someone above you
Other
Do you have any other evidence of the harassment?
Did you report these problems to the company/supervisor in writing, verbally, both, or neither?
Reported verbally
Reported in writing
Both: written and verbally
Neither
Other
Can you provide documentation of the writing?
Yes
No
What evidence do you have of the harassment?
When was the FIRST time the harassment happened?
When was the LAST time the harassment happened?
Why did the employer retaliate against you?
Getting injured at work
Filing a workers compensation claim with the employer
You reported them to a government agency for breaking the law or an unsafe workplace (Whistleblower)
For complaining to the employer about breaking the law or an unsafe workplace (Whistleblower)
Other
Briefly explain how they retaliated against you.
When did the
injury happen?
Brief explanation of how & why employer retaliated against you?
When was the last time the retaliation happened?
What is the injury?
Was there an accommodation required by your doctor?
Yes
No
What was the medical limitation?
How was the employer notified of medical limitations?
Verbal
Written doctors note
Email
Text
Did not give notification
Other
Did the employer accommodate these restrictions?
Yes
No
If not, did you make complaints regarding the lack of accommodation?
Yes
No
Written or verbal complaints?
Written
Verbal
Both
If the injury was an on the job injury, do you have a Workers Compensation Attorney?
No
Yes
Not a work injury
Did you file a complaint with a government agency?
No
Yes - EEOC
Yes - DFEH
Yes - Other
Which have you not received reimbursements for?
Cell Phone
Car
Personal Computer
What is the name of the company or employer?
*
What city and county is company located?
*
How many locations does the company/employer have?
How many years has the company been in business for?
How many employees does the company/employer have?
*
Do you have the name or contact info for any of the following?
Owner
Direct Supervisor
Firing Manager
HR Manager
None
Please provide the name and email of the OWNER
Please provide the name and email of the DIRECT SUPERVISOR
Please provide the name and email of the FIRING MANAGER
Please provide the name and email of the HR MANAGER
What was your date of hire?
*
What is/was your position?
*
What was/were your job duties?
*
What days do/would you work in any given week?
*
How many hours do/did you work in a single day?
*
How do/did you get paid?
*
Hourly
Salary
Daily
Other
How much are/were you getting paid?
*
Current employment status?
Fired
Quit
Still Employed
On Leave
On Disability
Other
When was termination date?
Why do you believe you were fired?
Did you find a job since you were terminated?
Yes
No
What was the date you started this new job?
Do you know if this is happening to other employees?
No
Yes
Unknown
Do you have their contact information?
Yes
No
Does not want to provide at this time
Please provide the contact information of the other employees. Let them know we will be contacting them.
What are your expectations in resolving this claim?
Please provide your check stubs, checks, earning statements and/or employee handbook
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Name of Intake Manager
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Alexa
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