Intake Questionnaire for Employment Matters

Today's Date:

Date(s) of Employment Difficulties:

Who referred you to us?
Please select one: Attorney Previous Client Family/Friends Other

Name:

Home Address:

Telephone(s):
Home:

Work:

Cell:

*Please specify above if there is a number you do not wish us to use to contact you.

Social Security Number:

Date of Birth:
 /   /  (dd/mm/year)

Age today:

Gender:
Please select one: Female Male

Race:

National Origin:

Marital Status:

Name of Employer with which you have an issue: :

Their Address:

Telephone:

Type of company/business:

Total number of employees (including part-time):

Number of employees at location where you worked (including part-time):

If more than one location, number of employees at all locations within 75 miles of location where you worked (including part-time):

Did your employer use a payroll company, employee leasing company or a management company?

If so, what was the name of the company?

Your question or comments:

Check any of the categories below that you believe your claim falls under:

Your Position at the Employer:

Date of Hire (or Application if not hired):
 /   /  (dd/mm/year)

Name and title of your direct supervisor:
Name  Title 

Name and title of any other supervisor(s) and/or manager(s) and/or owner(s) you reported to:
Name  Title 

If you believe you have been harassed or discriminated against, has anyone at work ever made inappropriate comments to you (e.g., about your age, sex, disability, race, color, national origin, religion, etc.)?

If so, please list the comment(s), the name of the person who made the comment, their position with the company, whether that person is a different age, sex, race, etc. than you, and whether anyone else heard the comment(s):

Has anyone at work engaged in any other inappropriate behavior toward you (e.g., making threats, touching you, etc. because of your sex, disability, race, color, national origin, religion, etc.)?

If so, please list describe the offensive behavior, the name of the person who engaged in the behavior, the person's position with the company, whether that person is a different age, sex, race, etc. than you, and whether anyone saw the behavior:

If you are disabled, did you request any accommodation from the employer or otherwise let the employer know you needed assistance?

If so, was any accommodation provided?

If so, describe:

Have you been:
Terminated?
Forced to resign?
Demoted?
Denied promotion?
Refused a job you applied for?
Other?

If any of the above has occurred, please state:

What date were you notified of the action?
 /   /  (dd/mm/year)

What date were you notified of the action?
 /   /  (dd/mm/year)

What date was the action taken?
 /   /  (dd/mm/year)

Who informed you the action was being taken against you?
Name
Title
Age
Sex
Race
National Origin
Marital Status

Is this the same person who actually made the decision? Yes:
If not, who was the person that made the decision?
Name
Title
Age
Sex
Race
National Origin
Marital Status

What was the reason given for the action?

Do you think the reason given was the real reason for the action? Yes:
If not, what do you think is the real reason for the action?

If feel the action was illegal, unfair or inappropriate, explain why:

Were other employees treated differently or more favorably? Yes:
If so, how?

Have other employees experienced the same type of problem? Yes:

If so, please explain:

Did you verbally report the problem to anyone at work? Yes:
If so, whom did you report the problem to?


When did you report it?
 /   /  (dd/mm/year)

What did you say?


What was their response?

Did you provide any written notice of the problem to anyone at work? Yes:
If so, who did you give it to?


When did you provide the notice?
 /   /  (dd/mm/year)

What did you write?


What was their response?

If terminated, what are the age, race, and sex of your replacement?
Age: Race: Gender:

If the action was taken against you because of absenteeism or tardiness, were the absences or instances of tardiness a result of your health, or the health of you spouse, children or parents?

If so, who has the health condition and what is the health condition:

How many days of work have you missed during the past 12 months due to this health condition?

If terminated, were you offered severance pay? Yes:
If so, how much?

Did you accept the severance? Yes:

Did you sign a release or waiver? Yes:

Did you sign anything else? Yes:

If so, what did you sign?

Did you have an employment contract? Yes:

Were you a public employee (i.e., employed by a government entity)? Yes:

Were you a member of a union? Yes:
If so, did you file a grievance? Yes:

Date:
 /   /  (dd/mm/year)

Outcome:

Have you found other employment? Yes:
No:
If so, what is the name of your new employer?


Address:




Telephone:


Position:


Date of Hire:
 /   /  (dd/mm/year)

Rate of Pay:

But expect to soon (explain):


And do not expect to soon (explain):

Have you filed for unemployment benefits? Yes:
If so, what is the status?

Have you lost money and/or benefits as a result of this employment problem? Yes:
If so, in what amount?

Have you experienced any physical or emotional problems as a result of this employment problem? Yes:
If so, please describe?

How were you paid by the employer?
Please select one: Hourly Salary Commissions Bonuses

Rate of Pay:

Did you occasionally work more than 40 hours per week? Yes:
If so, on average, how many hours per week did you work?


Were you paid overtime (time-and-a-half) for all hours worked in excess of 40 hours per week?

Did your employer fail to record all of the hours you worked and/or
make you work "off the clock" by:
Not allowing you to "clock in" or record your time until after you
actually started working?
Requiring you to "clock out" or stop recording your time before you
actually stopped working?
Requiring you to "clock out" or deducting time for lunch or other
breaks even though you were still working?

Have you conferred with any other attorneys concerning this case? Yes:
If so, please list the names of the attorney's consulted and state why no representation was undertaken:

Have you ever filed a claim for workers' compensation benefits? Yes: If so, when?
 /   /  (dd/mm/year)

What was the condition at issue?


Were benefits paid?

If you filed a claim for workers' compensation benefits while at the employer you are complaining about...
Have you reached maximum medical improvement? Yes:
Have you been released to return to work? Yes:
If so, have you notified the employer? Yes:

What was the result of your notification?

Did your doctor condition your return to work upon certain restrictions? Yes:
what are your restrictions, and are they temporary or permanent?

Have you ever filed a claim for disability insurance or social security disability benefits? Yes:
If so, when?
 /   /  (dd/mm/year)

What was the condition at issue?


Were benefits paid?

Have you ever filed for bankruptcy? Yes:
If so, when?
 /   /  (dd/mm/year)

What is the current status?

What do you want to accomplish through an attorney?

Have you filed a charge of discrimination? Yes:
If so, when?
 /   /  (dd/mm/year)

With whom?

Have you received a determination regarding your charge? Yes:
If so, when did you receive the notice?
 /   /  (dd/mm/year)

Are you aware of any kind of deadline with respect to your need for legal advice or representation? Yes:
If so, please explain briefly:

Have you ever been involved in any type of lawsuit? Yes:
If so, please describe what it involved, what the outcome was, and when it was:

If you feel there is other pertinent information that should be considered, please attach that information as well.

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Thank you, again, for your interest in the Presswood Law Firm, P.A.