1. Contact: (Phone or Email)
Name and Additional Phone # (optional)
2. Employer: (General description will suffice)
3. # of Employees: (Approximate number will suffice)
4. Length of Employment:
5. Position:
6. Salary:
7. Do you contend you were wrongfully terminated? If so, provide the following information: A. Date of termination:
B. Position of person who terminated you: C. What reason were you given, if any: D. If you disagree with the reason given, what do you believe was the cause of your termination? E. Are you re-employed yet?
B. Position of person who terminated you:
C. What reason were you given, if any:
D. If you disagree with the reason given, what do you believe was the cause of your termination?
E. Are you re-employed yet?
8. Do you contend you have been harassed or discriminated against? If so, provide the following information:
A. Position of person who has harassed or discriminated against you: B. Does this person harass or discriminate against you because of your age, sex (including sexual harassment), pregnancy, race, religion, national origin, disability, sexual orientation? If so, which one: C. If this person does not harass or discriminate against you because of one of the categories listed above, please provide a brief statement as to why you believe this person harasses or discriminates against you: D. Have you reported the harassment or discrimination to any supervisor or manager? If so, provide the following information: (1) Position of person receiving the complaint? (2) Date the complaint was lodged: (3) Was the complaint verbal or in writing: (4) Provide a brief description of your employer's response to your complaint: (5) Did the harassment or discrimination continue after your complaint? yes no E. Have you received a right to sue letter from either the DFEH or the EEOC? yes no If so, when:
A. Position of person who has harassed or discriminated against you:
B. Does this person harass or discriminate against you because of your age, sex (including sexual harassment), pregnancy, race, religion, national origin, disability, sexual orientation? If so, which one:
C. If this person does not harass or discriminate against you because of one of the categories listed above, please provide a brief statement as to why you believe this person harasses or discriminates against you:
D. Have you reported the harassment or discrimination to any supervisor or manager? If so, provide the following information:
(1) Position of person receiving the complaint?
(2) Date the complaint was lodged:
(3) Was the complaint verbal or in writing:
(4) Provide a brief description of your employer's response to your complaint:
(5) Did the harassment or discrimination continue after your complaint? yes no
E. Have you received a right to sue letter from either the DFEH or the EEOC? yes no
If so, when:
9. Do you contend you are owed wages, commissions, or tips by your employer? If so, provide a brief description of why you believe this money is owed and the amount of money you contend is owed:
10. Do you contend you were improperly denied a medical leave? If so, provide a brief description of why you believe the denial was improper:
11. If your situation is not covered above, provide a brief description of facts relevant to your claim: