Kalson Law | Employment Lawyer Ocean County, NJ

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Date of Birth :

How did you hear about our firm ?

If Referral, please indicate friend, family or Attorney name :

Employer :

Address :

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Your Job Title :

Supervisor Name :

Your Annual Salary or Hourly Wage :

Number of Employees :

Have you ever been (check all that apply) :

Fired or Laid Off

Demoted

Denied Promotion

Denied Job

Harassed

Other (please explain) :

BRIEFLY describe what happened to you :

What reason, if any, did your employer give for taking this action ?

What do you think was the true reason your employer took this action ?

Do you believe you have been discriminated against for any of the following reasons (Check all that apply) : Race Afro-American White Hispanic Asian Other

Sex : Male Female

Age : How old are you ?

Disability : How are you disabled ?

Pregnancy

Filing Worker’s Compensation Claim

Injured on the job : When ?

Reporting an improper activity

Other

Have you filed a Charge of Discrimination with the EEOC or any other agency ?

Yes No

If yes, what is the date of your filing and agency ?

Have you received a “Right to Sue” letter from the EEOC or any other agency ?

Yes No

If yes, what is the date on your Right to Sue letter ?

What specifically makes you believe you were discriminated against ?

Did anyone in the workplace make comments about race/sex/age/disability/etc ?

If so, who (supervisor, coworker, etc.) ?

What were the comments (please use exact quotes) ?

How long have you been employed with this employer ?

Have you had any evaluations ?

Yes No

Have you consulted with another attorney ?

Yes No

If so, who ?

Have you received any complaints or warnings about your work ?

Yes No

If so, please describe

Are you still working for this employer ?

Yes No

If no, have you found another job ?

Yes No

How much does it pay ?

Have you filed for Unemployment Benefits ?

Yes No

If yes, what was the result ?

If you were denied, what level of Appeal are you at :

What is the date of mailing on your Notice ?

Harassment Cases (answer these questions ONLY if you’ve been harassed) :

Name of Harasser :

Job Title :

Relationship (Supervisor, Co-Worker, etc.) ?

Please describe exactly what person said or did to harass you :

Did you complain to anyone about the harassment ?

Yes No

To whom (name, job title) ?

When (date) ?

What was their response ?

Was any action taken against the Harasser ?

Yes No

If yes, please describe :

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