If you would like your employment case to be reviewed, we strongly encourage you to first complete the Case Review Questionnaire. Doing so will allow this office to review your matter in a more efficient and expedient manner.

The Case Review Questionnaire is designed to provide this office with the basic and essential information needed to review your matter. Completing this form and providing it to this office does not mean this office is representing you as legal counsel. The form will be reviewed by this office and you should receive some feedback within the near future. The completion of this form, and review of this information, by no means establishes an attorney/client relationship between yourself and this office. This relationship can only be established after you and this office enter into a written attorney’s fee agreement.

GENERAL INFORMATION QUESTIONNAIRE

Please review this form and complete all information requested. If a question is not applicable to you, simply type "N/A" in the space after the question.

This information will be reviewed by this office in deciding whether this office is willing to represent you in a legal proceeding. The completion of this form, and review of this information, by no means establishes an attorney/client relationship between yourself and this office. This relationship can only be established after you and this office enter into a written attorney’s fee agreement.

The information contained herein is covered by the attorney/client privilege and should be completed and reviewed by the possible client of this law firm.

1. Personal and Family History
Full name
Current home address	City State Zip
Home phone
Business phone
Cellular phone
Pager
E-Mail Address
Your Social Security number
2. Place of Birth
Birthplace
Have you ever used any other date or place of birth? If so, explain.
3. Marriage Status
Are you presently married?	Yes No
Name of Spouse
Children, if so, state names and ages:
4. Your Employer – Pay Information In this section, you should provide the information regarding the employer that you are making a clam against.
Employer’s Name:
Employer’s Complete Address:	City State Zip
Employer’s phone Number
Number of employees in your State
Number of employees in other States
Date you started working there:
Your last day working there:
Your last job title while working there:
Were you paid by the hour or salary:	Hourly Salary
Beginning pay rate (either per hour or per year)
Ending pay rate (either per hour or per year)
Average number of hours you worked per week:
Immediate Supervisor’s Name/Title
Are you a member of a labor Union?	Yes No
If so, what union:
As part of this job, were you required to attend any type of binding arbitration to resolve any employment disputes?	Yes No
5. Allegations of Discrimination/Harassment: In this section, you should provide the information regarding the employer that you are making a clam against.
If you believe you were discriminated or harassed at work, indicate below if you believe any of these reasons were the basis for your discrimination or harassment? (note: you can check more than one if necessary)
Race Age Religion Pregnancy Gender/Sex Nationality Disability (describe below) Other (such as exercising your workers compensation rights, or reporting illegal activity of your employer to your supervisor or a governmental agency)
If you checked “disability” or “other,” please describe the disability at issue or the “other” circumstances:
6. Allegations of Discrimination/Harassment:
a. Description the conduct of your employer that you believe was discriminatory or harassing:
b. Any comments, jokes, or other actions that were part of this incident (describe them, who made them?):
c. If the incident involves being treated differently than another employee, please describe the cicumstances and the name/position of the other employee(s) being treated differently.
d. the names of any witnesses, what they witnessed, and their positions:
e. the date(s) such conduct occurred (to the best of your recollection). If they occurrecd over a period of time, state the time frame:
f. Did you report this conduct to any person in the company, if so, who, when, and what happened as a result of your complaint:
g. Do you think the company retaliated against you in any manner for reporting the incident, if so, explain how.
7. Job Performance:
Did you have performance reviews conducted while employed? If so, state each date a performance review was conducted (anually, etc.), state who provided you the review and their job title, and give a general statement as to whether it was a good review. You should describe any performance issues that were raised in each review.
Were you ever suspended, punished, or reprimanded before by this employer? If so, describe.
8. Termination:
If you were terminated by this employer, please decribe in detail the meeting that was held (or conversation) when you were terminated. This should include the date, who was present and their position, who terminated you and their position, and any reasons that were given for the termination.
9. Resignation:
If you resigned from this employer, please state the reasons why you resigned.
10. Charges of Discrimination:
Have you filed any charges of discrimination relating to any of the above described incidents with either the Equal Employment Opportunity Commission (EEOC), a State Commission on Human Rights, or a City Human Rights Commission, or any other governmental agency? If so, name the agency and state when it was filed?
11. Employment since leaving the Discriminating Employer:
If you have been employed since leaving the discriminating employer, please provide the following information for the first place you worked since leaving.
Employer’s address
Ending date
Beginning date
Job classification
Beginning pay rate
Ending pay rate
Reason(s) for leaving
Immediate Supervisor’s Name/Title
12. Educational Background
What education have you had, including any special job training (list high school, college, college courses, degrees, etc. and dates of each of these)
13. Other lawsuits:
If you were a party to another lawsuit in your life (this is only where there was formal court proceedings), including divorces and claims for workers compensation, state the nature of the lawsuit, what Court it occurred in, what date was the lawsuit filed, and the outcome.
14. Criminal History:
Other than speeding and parking tickets, state any incident that you were charged with any criminal violation, when this occurred, where it occurred, and the outcome (i.e. plea agreement, conviction).
15. Medical Care:
If you have seen any doctor, counselor, pschologist, or other health care provider for any reason relating to you allegations of discrimination, please provide the following: Name of health care provider, address, dates that he/she was seen, reasons for seeing this person.
16. How did you learn about this office:
Please describe how you learned to contact this office for review of your matter (such as referral, advertisement, internet search, etc…).