Employment - Potential Client Questionnaire

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Name and Contact Information

Name of potential client(Required)

Please know that all information you share with us throughout this questionnaire is confidential. We are asking these questions so we can appropriately evaluate your potential claims.

First Last

Phone(Required)

Can we text you at that phone number?(Required)

Yes

Email Address(Required)

Mailing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

What is your date of birth(Required)

Information about your employment (please answer these questions for the potential client)

Name of Employer Involved(Required)

Approximate number of employees company-wide(Required)

Fewer than 5

6-20

21-50

51-100

More than 100

Total length of your employment with this company(Required)

Less than 6 months

6 – 12 months

1-4 years

5-10 years

More than 10 years

Are you still employed with this company(Required)

Yes

Unsure

Explain your current employment status:(Required)

What is your current position title(Required)

On what date did your employment end(Required)

What was your position title at the time your employment ended(Required)

Reason for your employment ending(Required)

Termination/Fired

Resignation

Something else

What reason did the employer give for your termination

Describe in a couple of sentence what your employer would say was the reason for terminating your employment. We will ask you separately what you think happened.

What was the reason you resigned

Describe in a couple of sentence why you decided to resign when you did.

Describe the reason for which your employment ended

If you did not resign and you were not terminated, please describe in a couple of sentences the reason why your employment ended.

Have you found other work(Required)

Yes

On what date did you return to work

Who is your new employer

Have you been looking for other work?

Yes

Why haven't you been looking for work?

Issues with your employment

Please indicate if your situation involves any of the following:(Required)

Please select all issues you believe your case may involve.

Retaliation (including for reporting harassment or discrimination)

Discrimination

Harassment/Bullying/Hostile Work Environment

Injury/Disability/Health Issues (including disability discrimination, harassment, or FMLA issues)

Something else

What do you think motivated your employer to retaliate against you?

I complained about harassment or discrimination based on age, race, sex, sexual orientation, gender identity, disability, religion, or national origin

I complained about some other type of harassment or discrimination

I reported a work injury or got workers compensation benefits

I reported or complained about a workplace safety issue or an OSHA violation

I reported or complained about my employer not following the law

I fulfilled mandatory abuse reporting obligations

Something else motivated my employer

If you answered "something else", indicate what you believe motivated the retaliation:

What negative consequences have you experienced?

Poor performance review / Performance improvement plan

Discipline

Denied promotion

Unequal pay

Termination

Something else

Describe the other negative consequences you experienced:

What do you think motivated the harassment or discrimination?

Age

Disability

Gender Identity

National Origin

Race

Religion

Sex

Sexual Orientation

Something else

What is your gender identity?

What is your national origin?

What is your race?

What is your sex?

What is your sexual orientation?

If you answered "something else", indicate what you believe motivated the harassment or discrimination:

What causes you to believe the harassment or discrimination was motivated by one of these things?

Help us understand why you think age/disability/gender identity/national origin/race/religion/sex/sexual orientation was motivating the behavior.

When did the most recent harassment occur?

Within 1 month

2-6 months ago

6-12 months ago

More than 12 months ago

What is the nature of the harassment?

Please select all of the categories that apply to your situation.

Inappropriate slurs or language

Inappropriate “joking”

Inappropriate touching or gestures

Excessive supervision or micromanagement

Unreasonable performance expectations

Negative performance feedback

Unwarranted discipline or write-ups

Something else

Please provide one or two examples for each item you checked:

In a couple of sentences, give brief examples of the harassment. We may gather more detail or context from you a later point.

Have you complained to anyone about the harassment or discrimination?

Yes

Tell us about the complaint or report you made and the result of the complaint

Please help us understand to whom you complained, when, and what happened as a result of your complaint.

What negative consequences have you experienced?

Poor performance review / Performance improvement plan

Discipline

Denied promotion

Unequal pay

Termination

Something else

Describe the other negative consequences you experienced:

What is the health condition or disability?(Required)

Since you indicated your employment issue is related to a health condition, we need some basic information about your health. The information you share with us is confidential.

Have you applied for or do you already receive Social Security Disability benefits?

Yes

Not sure

Please indicate which of the following issues apply to your situation:

Discrimination because of my disability

Reasonable accommodation

FMLA or Attendance concerns

Work-related injury (including concerns about restrictions or attendance)

Something else

Have you already requested an accommodation from your employer?

Yes

Unsure

Tell us about your requested accommodation:

Please share when you made the request, what specifically your requested, and how your employer responded.

Tell us what you believe your employer did wrong related to a reasonable accommodation:

It looks like you have not requested an accommodation or are unsure whether you have. Please help us understand what your concern is about the reasonable accommodation issue.

What are the attendance or absence issues you are worried about?

I have already been disciplined or terminated for attendance

I have already missed a lot of work and am worried that I might be disciplined or terminated

I need to take some time off for a health reason

I have questions about FMLA, short-term disability, or long-term disability benefits

Something else

Approximately how much work have you missed?

Help us understand your attendance. If you haven’t been going to work at all, let us know the last date you worked. If you have been going to work, help us understand how much time off you have been taking.

Approximately how much work do you anticipate missing?

Have you requested FMLA?

Yes

Not sure

Tell us about your request for FMLA:

Help us understand when you requested FMLA, whether it was approved, and how much was approved.

Please explain why you are unsure:

Help us understand why you are unsure whether or not you have requested FMLA.

Describe the attendance or absence issues you are worried about:

When was your work-related injury?

Please describe the injury:

Help us understand what body parts were injured.

Please describe any restrictions you have:

Help us understand in a couple of sentences whether you are currently or have been on any restrictions, including light duty or no work.

What are your main concerns about your work injury?

Help us understand what employment-related concerns you have about your work injury that have caused you to reach out to us.

What is the health-related concern you have?

Help us understand what health concern you have that is related to your employment.

What is the employment concern that you need help with?

Help us understand what caused you to reach out to our office.

Is there anything else you think we should know?

Employment – Potential Client Questionnaire

Name and Contact Information

Information about your employment (please answer these questions for the potential client)

Issues with your employment