Name: Address City State Zip Email address: Phone number: Yes No Where you fired? When were you fired? If not fired, do you think you are about to be fired? When? What reason where you given for being fired/about to be fired? Do you think it is really for a different reason? If so, what reason? Yes No Did you quit? If you quit, then 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? Yes No Are they still employed there? Yes No Did anyone witness the Discrimination or harassment? Who witnessed it? What did they see or hear? Yes No Are they still employed there? Did you report the discrimination or harassment to any government agency? Yes No Which agency and when? Yes No Did you file a written complaint?? Did you receive anything in writing notifying you that you can file a lawsuit? Yes No When did you receive it?? Yes No Are you presently employed? 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.

Representing Abused Employees and Wrongfully Accused Employers

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