Name:
Address:
City, State, Zip:
Email:
Phone Number:

Questions Regarding Your Situation

Were you fired? Yes No

When were you fired?

If not fired, do you think you are about to be fired? Yes No

When do you expect to be fired?

What reason where you given for being fired, or for being about to be fired?

Do you think it is really for a different reason? If so, what reason?

Did you quit? Yes No

If you quit, hen when?

Why did you quit?

Were you or are you being harassed? Yes No

When was the last time you were harassed?

What (briefly) constituted the harassment?

Why do you think you were being harassed? (race, age, gender, other - please name)

Did you report the discrimination or harassment to anyone in the company? Yes No

Who did you report it to and what is their position?

Are they still employed there? Yes No

Did anyone witness the discrimination or harassment? Yes No

Who witnessed it?

What did they see or hear?

Are they still employed there? Yes No

Did you report the discrimination or harassment to any government agency? Yes No

Which agency and when?

Did you file a written complaint? Yes No

Did you receive anything in writing notifying you that you can file a lawsuit? Yes No

When did you receive it?

Are you presently employed? Yes No

Where are you presently employed?

How long have you been employed?

What do you earn?

If you were fired or quit, how long where you there?

How much were you making?

Please indicate any other facts that you believe are important. We need to know what your employer did to you, what reason you think they did it which you believe it illegal, and what damage or loss you suffered because of what they did.