Current Employment Status—Please choose an option—EmployedTerminatedOn LeaveSuspended
Date of Birth
Make it standard as 000 If you do not have a social please enter "0000". This information is often required by employers to identify your file and enables the release your personnel records in a timely manner.
Does your employer operate under a different name than the name listed on your paycheck? —Please choose an option—YesNoUnsure Does your employer have a corporate location that is different from the location you worked at? —Please choose an option—YesNoUnsure
When did your employment begin? Are you still working for your employer? —Please choose an option—YesNoTerminatedResignation When was the last day you worked? (If on leave, indicate the last date you were at Defendant prior to going on leave and if you are on leave, indicate your return date) When was your official termination/resignation date? INCLUDE NAME, RELATIONSHIP, AND PHONE NUMBER
Please identify the person who you interacted with while employed by the Defendant that is responsible for handling legal claims: If you are unsure, please identify the most senior level manager or HR representative that you interacted with while employed by Defendant (can have Defendant’s name here) for whom you have contact information.
Were you a member of a union? —Please choose an option—YesNo
Did you receive any demotions your last year working? —Please choose an option—YesNo Have you ever filed for bankruptcy or been convicted of a felony? —Please choose an option—YesNo Did you file any complaints with a government agency related to your employment concerns? Ex: DFEH, OSHA, Labor Commissioner, etc. This could have been while you were employed or after you were no longer employed.—Please choose an option—YesNo Did you ever file a workers compensation claim for an on the job injury? —Please choose an option—YesNo
This section captures all information related to possible claims under the labor code for wage & hour violations. Often times there are claims we are able to pursue that our client's did not know exist when first reaching out.
Did you fill out an I.R.S Form W-4 at the start of your employment? —Please choose an option—YesNo Did your employer issue you an I.R.S. Form W-2 at the conclusion of the last tax year? —Please choose an option—YesNo How were you paid? —Please choose an option—Hourly Wage/RateWeeklyOther Did you receive or have online access to itemized pay stubs?—Please choose an option—YesNo
Were you eligible for any bonus compensation or commissions in the last year? —Please choose an option—YesNo
List your hours worked per day on a regular basis: (Enter "0" for any day not worked)
Were you ever not paid wages for time worked for your employer?—Please choose an option—YesNo
Did you ever perform work before clocking in or after clocking out? (Do not answer yes, if the time was already entered in the prior question) —Please choose an option—YesNo
Were you required to use any personal items such as: your cell phone, computer, vehicle, or home/apartment to complete your job duties? If so, list the items and for what use.—Please choose an option—YesNo
Did you ever work more than 8 hours in a day? —Please choose an option—YesNo For the times you worked more than 8 hours in a day, were you paid overtime wages? (Overtime wages are equal to one and a half times your regular hourly rate of pay) —Please choose an option—YesNo Did you ever work more than 40 hours in a work week? —Please choose an option—YesNo For the times you worked more than 40 hours in a week, were you paid overtime wages? —Please choose an option—YesNo
Did your employer pay you rest break penalties/pay on your paycheck for each missed rest break? —Please choose an option—YesNo
Did you regularly work more than 10 hours per shift? —Please choose an option—YesNo For times that you worked more than 10 hours per shift, were you able to take a second uninterrupted 30-minute off duty meal period? —Please choose an option—YesNo Did your employer have posted signs regarding minimum wage laws and other California labor laws? —Please choose an option—YesNo
This section captures all details related to claims based upon being a member of - or being closely associated with - a protected class of persons protected by law. This includes claims of discrimination, retaliation, harassment, failure to accommodate, failure to engage, and failure to prevent harassment, discrimination, or retaliation.
Were you treated differently by your employer, manager, or coworkers because of any of the following? —Please choose an option—• Race, colorAncestry, national originReligion, creedAge (40 or over)Disability, mental and physicalSex, gender (including pregnancy, childbirth, breastfeeding or related medical conditions)Sexual orientationGender identity, gender expressionMedical conditionGenetic informationMarital statusMilitary or veteran status Did you make any complaints of improper treatment related to you (or a co-workers) to a supervisor or management pertaining to the PROTECTED CLASS? —Please choose an option—YesNo Did you experience discrimination as a result of your PROTECTED CLASS? Discrimination means you were unable to perform your job; not offered advancement or promotion; or demoted or terminated. —Please choose an option—YesNo Do you have any witnesses who can verify how you were treated as a result of your PROTECTED CLASS? —Please choose an option—YesNo Did you require an accommodation from your employer in order to perform your job? —Please choose an option—YesNo If you requested an accommodation from your employer, what was the accommodation and did you provide any documentation with your request? —Please choose an option—YesNo
This section captures information related to protected activity that you may have engaged in while employed. This includes activities that implicate Labor Code Sections 98.6, 1102.5, 132(a), 6399, 246.5 etc.
Did you complain about any of the following workplace conduct?(EX: Illegal or unethical conduct by a co-worker(s) or manager(s) Nonpayment of wages) —Please choose an option—YesNo Did your employer treat you differently in any way following your complaints about Illegal or unethical conduct by a co-worker(s) or manager(s), Nonpayment of wages? —Please choose an option—YesNo
Did you take or attempt to take sick leave in the last year of your employment? —Please choose an option—YesNo
Did you take or attempt to schedule medical/family leave in your last year of employment? —Please choose an option—YesNo
Have you filed any complaint with any of the following agencies? —Please choose an option—DFEH - Department of Fair Employment and HousingEEOC - Equal Employment Opportunity CommissionCivil Rights OfficeOtherNone
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