Employee Questionnaire

Disclaimer:  Completing this form does not create any attorney-client relationship.  Thus, no information provided by you shall be considered confidential or protected by an attorney-client confidentiality until our office is officially and adequately retained as your attorney and allowed a full opportunity to review for any conflict of interest.

Your First Name:

*

Your Last Name:

*

Your Middle Name (Optional):

 Your Birth Date:

Your Telephone Number :

Your Cellphone Number (Optional):

Best time to call you:

Best day to call you:

 

 

1. Check all labor issues that you believe may apply to your situation:

Overtime Violation
No W2/Checks
Discrimination
Disability Discrimination
Minimum Wage Violation
No Meal/Rest Breaks
Harassment
Whistle Blower
Unpaid Commission
Unpaid Expenses/Mileage
Wrongful Termination
Retaliation
Hostile Work Environment
Missclassification
Split-Shift
Sexual Harassment

If other, please describe: 

 

 

2. Company:

                                                           

What is the name of the Company you work for?


What type of Company is it?

What is the approximate number of employees at this Company?

What year was this Company established?

What is your title at that Company?

If you are a Manager, how many people do you manage?

Are there any other lawsuits against your Company?
Yes
No

If so, what type of lawsuit?

Are you still working at this Company?
Yes
No

When did you start and end at this Company? 
to


If you are no longer working for this Company, what was your reason for leaving?
Resign
Laid Off
Fired

If you were fired, please describe:

Have you filed for Unemployment since leaving this Company?
Yes
No

If so, are you currently receiving Unemployment? 
Yes
No

Did you ever make any complaints to the Company about labor issues? If so, what were the complaints?
Please describe:

Who did you make the complaint to? 
Supervisor
Human Resources Department
President/Owner
Co-worker
 Other: 

How did the company respond to your complaint? Please describe:

 

3. The Pay & Hours:

                                                                                       

How are you paid? 

By Hour
By Salary
Commission
Bonus
Independent Contractor
Profit Share

How much are you paid:
Per hour? $
Monthly Pay/Salary: $
Estimated Bonus/Tips: $

What method of payment?
Check
Cash
Other:

Please enter your total working hours for each day:

Monday total hours per day:

Lunch hours: 

Tuesday total hours per day:
Lunch hours: 

Wednesday total hours per day:
Lunch hours: 

Thursday total hours per day:
Lunch hours: 

Friday total hours per day:
Lunch hours: 

Saturday total hours per day:
Lunch hours: 

Sunday total hours per day:
Lunch hours: 

Are there any special circumstances for your work week? If so, please specify:

 

 

4. Attorneys:

                                                                                                    

Have you spoken to another attorney before?

Yes
No

Who was the attorney that you have spoken to?

Have you retained an attorney, and if not, why?

 

 

I acknowledge that the foregoing information I am providing is solely for the purpose of having my case reviewed. I understand that the submission of this information does not form an attorney-client relationship. I certify that the information I have provided in this questionnaire is true to the best of my knowledge and belief.*

 

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