Employment - Investigation Questionnaire

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EMPLOYMENT INFORMATION

The following questions are about the employer involved in your case.

Name of the person who hired you:(Required)

Please give the name or a description of who it was. If you do not recall, please state so.

Title of the person who hired you:(Required)

Provide the sex, race, approximate age, and any known disabilities of the person who hired you:(Required)

Please provide the following information about each position you have held with the employer at issue:

Positions held at the place of employment:(Required)

Please list all titles you have held during your employment and approximate dates you held that title. If you need to add multiple positions, please check the “+” sign at the end of the line.

Your position title:

Dates you held this position:

Name and title of your direct supervisor when you held this position:

Provide the sex, race, approximate age, and any known disabilities of this supervisor:

Did you receive regular performance evaluations?(Required)

Yes

Other

Do you have any copies of any evaluations from the last 12-24 months?(Required)

Yes

Identify anyone else who reported directly to the supervisor you had as of the date of your employer's wrongdoing:(Required)

Please provide as many names and titles as you know. If you do not remember all individuals, please note that. You may add additional lines by clicking the “+” sign.

Name

Title

Sex, race approximate age and any known disabilities

Who do you believe was involved in making the employment decision at issue:(Required)

Please provide information about all individuals who you believe influenced the decisions your employer made about your employment. Briefly describe what you believe the individual did: For example, “recommended my termination to HR”; “communicated discipline to me”; “signed termination letter”

Name:

Title:

What was this person's involvement?

DAMAGES

Financial losses

How were you compensated?(Required)

Hourly

Salary

Other

What was your hourly rate?(Required)

What do you estimate your total annual take-home pay to be?(Required)

Please indicate how much you typically made or expected to make in a year, including both regular and overtime pay.

What was your annual base salary?(Required)

Describe any bonuses, commissions, or other compensation you received in addition to your base wages or salary:(Required)

Please help us understand any additional compensation you were typically eligible for. If none, please state so.

Please select which of the folllowing types of benefits you received through this employer:(Required)

Retirement/Pension contribution

Profit-sharing plan

Health insurance

Dental/Vision insurance

Short term disability insurance

Long term disability insurance

Has your employment ended?(Required)

Yes

Other

When did your employment end?(Required)

Please enter a specific date if possible.

Have you filed for unemployment benefits?(Required)

Yes

What was the result?(Required)

Have you found other work?(Required)

Yes

Other

Are you actively looking for other work?(Required)

Yes

Other

Please explain why your are not actively looking for other work:(Required)

Please provide the following information for each new employer. If you have had more than one employer please provide this information for each employer(Required)

Name of new employer:

Address of new employer:

Position with new employer:

Start date:

End date:

What is your hourly pay/annual salary?(Required)

Emotional Harm

Describe the emotional or mental health impact that this employer's actions have had on you:(Required)

For example, how did you feel the moment you learned of the employer’s decision? What was it like to tell friends and family members? If you were terminated, how did the unemployment period feel to you? What was it like starting to look for work? Or starting a new job?

Have you sought professional care for your mental or emotional distress?(Required)

Please indicate whether you have sought treatment for distress related to your employer’s conduct.

Yes

Other

Where have you sought care for your mental or emotional stress (counseling, medication, etc.):

Provider(s):(Required)

Name of provider:

Name of clinic:

Address of the clinic:

When did you first treat at this location for any reason:

PERSONS WITH KNOWLEDGE

We would like to get information about individuals who you believe have knowledge that will help with your case. This includes two types of potential witnesses: 1) Individuals who witnessed or are aware of events that occurred at work; and 2) Individuals who have knowledge about how your employer’s conduct has affected you either financially or emotionally

Please identify the witnesses who you believe have this information:(Required)

Relationships to you include: Co-worker, supervisor, community member; customer, family member, etc.

Name:

Address (if known)

Phone number (if known)

Email address (if known)

Relationship to you:

What does this person know?

Is there anything else you would like us to know?

Gathering Helpful Documents

You are likely in possession of documents that may help us better understand and, ultimately, prove your case. We want to gather from you at this time any documents you have not already provided to us.

Please indicate if you have any of the following types of documents:(Required)

Emails concerning the events involved in your case

Text messages concerning the events involved in your case

Audio or video recordings concerning the events involved in your case

Personnel file documents, such as evaluations, discipline, termination notices, etc.

Employee handbooks or other similar policy and procedure documents

Any other documents given to you by the employer involved

I don’t have any of the above

How would do you want to get us these files?(Required)

Please let us know how you prefer to get these documents to us.

Upload now

Mail, fax, or physically bring to the office

I would like someone to contact me to discuss options

Other

Please upload any files you have

Drop files here or

Max. file size: 50 MB.

Mailing, faxing or bringing documents to us

Fax: 319-365-1114 | RSH Legal 425 2nd St SE, Suite 1140 Cedar Rapids, IA 52401 | Monday – Friday, 8:30 am – 5:00 pm

Employment – Investigation Questionnaire

EMPLOYMENT INFORMATION

Please provide the following information about each position you have held with the employer at issue:

DAMAGES

Financial losses

Emotional Harm

Where have you sought care for your mental or emotional stress (counseling, medication, etc.):

PERSONS WITH KNOWLEDGE

Gathering Helpful Documents

Mailing, faxing or bringing documents to us