1. Name
2. E-mail Address
3. Home Address
4. City/State/Zip
5. Date of Birth
6. Social Security Number
7. Home Phone
8. Work Phone
9. Cell Phone/Pager
10. Employer Present
11. Employer Previous
12. Who referred you?

13. Do you have a Facebook or MySpace account?

    YesNo

14. Nature of Complaint

    Sexual Harassment Whistleblower
    National Origin Disability Discrimination
    Sexual Orientation Discrimination
    Racial Discrimination/ Wrongful Termination Family Medical Leave Act
    Harassment Refusal to do Illegal Act
    Wage & Hour Religious Discrimination
    Cancer Discrimination Age Discrimination
    Pregnancy Discrimination Defamation
    
    
15. Against what employer do you wish to complain?
16. Date of Hire
17. Date of Termination
18. Salary/Wage
19. Occupation
20. Why were you terminated?

21. Have you, or do you plan to file bankruptcy?

    YesNo

22. Have you filed a charge with the Department of Fair Employment and Housing, Equal Employment Opportunity Commission, U. S. Department of Labor, or California Labor Commission? If so, please attach a copy of your charge to this intake questionnaire.

    YesNo
23. Agency

24. Have you received a RighttoSue letter from any agency? If so, please attach a copy of your Right to Sue letter to this intake questionnaire.

    YesNo
25. Agency

26. Have you filed a Worker's Compensation claim against this employer?

    YesNo

27. Have you applied for Unemployment Benefits?

    YesNo

28. Have you applied for Disability Benefits?

    YesNo

29. Did you receive two 10 minute breaks each day?

    YesNo
30. Explain

31. Did take an uninterrupted 30 minute lunch break each day?

    YesNo
32. Explain

33. Did your employer consider you exempt from overtime?

    YesNo
34. How often did you work overtime?

35. Were you paid for all hours of overtime worked?

    YesNo
36. At what hourly rate?

37. Were you paid more than your normal pay for missed 10 minute breaks or 30 minute lunch breaks?

    YesNo
38. Explain

39. Did you perform any work off the clock?

    YesNo
40. Explain
41. How many hour (nonmanagement employees performed the same type of work as you at this company?

42. Have you previously consulted with another attorney concerning this matter?

    YesNo
43. If yes, with whom and when?
44. Please give a brief statement of the facts

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