Online Consultation: Unemployed

Personal Data

Salutation

First Name Please enter your first name.

Last Name Please enter your last name.

Marital Status Single Married Divorced/Separated Widowed

Spouse's First Name

Last Name

Number of Children Under 21

Number of Children Over 21

Street Address

Address Line 2

City

State

Zip Code

Email Address

Home Telephone

Fax Number

Race

Gender Male Female

Religion

Date of Birth

Social Security Number

In which country were you born?

If other, please identify

Do you have a disability or believe your employer perceived you as disabled? Yes No

If Yes, please describe the nature of the disability and how it affects you

What would you like our firm to do for you? (Please include any specific questions that you have)

Current Employer Data

Employer

Employer Address

Address Line 2

City

State

Zip Code

Business of Employer

Employer's Phone Number

No. of employees at your work site

Total No. at all worksites

Name of Chief Executive Officer

Name of Human Resources or Personnel Director

Does your employer do business with the State of Ohio? Yes No

Does your employer do business with the U.S. Government? Yes No

Does your employer do anything wrong or falsely in its dealings with either government? Yes No

Does your employer have any written work rules or policies? (If Yes, please provide) Yes No

Union Activity (if applicable)

Name of Union

Have you filed a grievance about the subject matter of this consultation? Yes No

If Yes, what is the status of your grievance?

If No, why Not?

Employment History Data (with employer)

Position/Job Title

Department

Date of Hire

Pay Rate or Salary ($)

Were you paid

Hourly Paid Employees (do not fill out if you were paid a salary)

If you are hourly paid, were you paid for all hours you work? Yes No

Were you paid time and one-half your regular hourly rate for all hours worked over 40 hours in a week? Yes No

Salary Paid Employees (do not fill out if you were paid hourly)

If you were paid a salary,were you paid extra for hours your work over 40 in a week? Yes No

If you were not paid extra for hours you work over 40 in a week, did you:

a) Supervised two or more employees at all times? Yes No

b) Were you a professional in the traditional sense - doctor, lawyer or licensed (e.g., architect or teacher) or artistic (e.g., dancer, singer, painter of pictures)? Yes No

c) Did you have independent discretion to interpret and implement company policy? Yes No

Did your employer dock your pay for partial day absences? (Could be caused by personal or family member illness,doctor or dentist appointment, or any other reason.) Yes No

Was your regular salary docked for:

a) Lack of work? Yes No

b) Jury duty? Yes No

c) Attendance as a subpoenaed witness? Yes No

d) As a penalty for violation of work rules? Yes No

e) Temporary military duty (e.g., weekend or two week summer duty)? Yes No

Supervisor's Name and Job Title

What promotions or demotions did you receive during the course of your employment? (Please give approximate dates and identify the positions by title.)

What other transfers or reassignments, if any, did you receive during the course of your employment? (Please give approximate dates and identify the positions by title.)

Please indicate the amount of any pay increases or decreases that you have received during the last three years? (Please indicate which increases are merit increases.)

This year

Merit increase? Yes No

Last year

Merit increase? Yes No

2 years ago

Merit increase? Yes No

3 years ago

Merit increase? Yes No

Did you receive any awards or commendations at this company in the last 5 years? Yes No

If Yes, please list (with approximate dates, if known)

In the last three years of your employment with this company, did you complain about any employment practices or help any other employee who did? Yes No

If Yes, please explain

Were you ever discharged or forced to resign from prior employment? Yes No

If Yes, state the name(s) of the employer(s) and the year?

Check the statements which apply to you I had a written job contract or agreement. (If Yes, please provide a copy to our office).

I have a letter or document discussing the terms of my employment. (If Yes, please provide a copy to our office).

The company has an employee handbook or manual. (If Yes, please provide a copy to our office).

Factual Information Regarding Your Situation

Date of Termination

Date Notified of Termination

Approximate date of first adverse action against you by your former employer i.e., when were you first Notified of your termination and/or discriminated against?)

What did the Company say is the reason your employment was terminated?

Who made the decision to terminate your employment?

Which of these individuals, if any, participated in the decision to hire you?

Do you believe you were treated differently than other employees? Yes No

        	If Yes, please provide as many names of other persons that were treated better than you and identify each person's age, sex, race, religion, disability, or national origin if different than yours. If you do not specify these characteristics for a person, we will assume such individual is similar to you in those respects. Please use additional space at end of questionnaire to list others.
        

First Name

Last Name

Age

Religion (if known)

Sex Male Female

National Origin/Race Same Other

Disability Yes No

First Name

Last Name

Age

Religion (if known)

Sex Male Female

National Origin/Race Same Other

Disability Yes No

First Name

Last Name

Age

Religion (if known)

Sex Male Female

National Origin/Race Same Other

Disability Yes No

First Name

Last Name

Age

Religion (if known)

Sex Male Female

National Origin/Race Same Other

Disability Yes No

What are the names of persons who may support you and have knowledge about the testament you have received? Please provide telephone numbers. Summarize each person's knowledge and how it supports you.

Has anyone else been treated like you by this employer to your knowledge? Yes No

        	If Yes, please provide as many names of other persons that were treated like you and identify each person's age, sex, race, religion, disability, or national origin if different than yours. If you do not specify these characteristics for a person, we will assume such individual is similar to you in those respects. Please use additional space at end of questionnaire to list others.
        

First Name

Last Name

Age

Religion (if known)

Sex Male Female

National Origin/Race Same Other

Disability Yes No

First Name

Last Name

Age

Religion (if known)

Sex Male Female

National Origin/Race Same Other

Disability Yes No

First Name

Last Name

Age

Religion (if known)

Sex Male Female

National Origin/Race Same Other

Disability Yes No

First Name

Last Name

Age

Religion (if known)

Sex Male Female

National Origin/Race Same Other

Disability Yes No

Do you think you may have been discriminated against on basis of Age
Gender
Race
Disability
National origin
Religion
Workers' comp. claim
Other

If you checked any of the blocks above, please explain

Did your employer treat you differently than any promises/policies/rules would require? Yes No

If Yes, please explain

To your knowledge, was your employer or the parent corporation experiencing financial problems? Yes No

If Yes, please explain

Prior to the adverse action, did you receive other warnings (verbally or in writing) or were you placed on probation? Yes No

If Yes, please explain and include copies of all relevant documents

After Your Termination...

Do you know if someone else now holds your former position or the position you were seeking? Yes No

If Yes, who: First Name

Last Name

Sex Male Female

Age

Race

Were any other employees terminated at or about the same time? Yes No

If Yes, how many, if any, were in your department?

Since your termination, have you told anyone at the company that you are thinking of taking legal action against the company? Yes No

Have you filed a Charge with any government agency about your situation? Yes No

If Yes, please include copy and answer questions (a) through (d):

(a) When did you file your charge?

(b) What is the present status of your charge?

(c) Have you received a Notice of Right to Sue letter Yes No

(d) Have you received a Dismissal Notice? Yes No

(a) If so, when? (If you have copies of the Charge and/or Right to Sue letter, please provide)

Have you contacted other attorneys or agencies regarding your present claim? Yes No

If Yes, whom and when?

Damages Suffered as a Result of Employer's Actions

Is there a severance plan? Yes No

Did you receive severance pay? Yes No

If Yes, what does the severance package consist of?

Did you sign any document(s) in order to receive your severance? (If Yes, please include any copies.) Yes No

Did you seek unemployment compensation? Yes No

If Yes, did your employer contest your rights to the benefits? Yes No

What was the outcome?

Have you been employed since your termination? Yes No

If Yes, please state each employer's name, the dates of employment, and your earnings

Did you receive health or retirement benefits provided by the company? Yes No

If Yes describe

Have you suffered other financial losses?

Was your physical and/or emotional health affected by your employer's treatment towards you? Yes No

If Yes, in what way?

Are you seeking any kind of treatment from a health care professional as a result of the employer's treatment? Yes No

If Yes, identify the health care professional, the dates of treatment and any prescribed medication.

Have you ever been involved in litigation before? Yes No

If so, give dates and the subjects of the lawsuits or charges:

Other Relevant Information Regarding Your Employment

Please provide any additonal relevant information, regarding your employment

Documents

Are you providing any documents to us? Yes No

If Yes, by Fax or Mail? Fax Mail

How Did You Find Us?

Name of person(s) who referred you to our firm

Name of attorney to whom you were referred

Why did you select our firm?

Online Consultation: Unemployed

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