BASIC INFORMATION Name
CONTACT INFORMATION SPOUSE/SIGNIFICANT OTHER REFERRAL MARRIAGES/DIVORCES CHILDREN EDUCATIONAL HISTORY EMPLOYMENT HISTORY (Current/Most Recent Employer First) INFORMATION REGARDING YOUR CLAIM
This is the individual or business that you believe discriminated against you or treated you wrongly.
ATTACH A COPY OF YOUR W2 AND OR PAY STUB FOR EMPLOYER VERIFICATION
Drop files here or
Max. file size: 256 MB. Type Of Discrimination
(Select All That Apply)
List all person(s) that you believe discriminated against you or treated you wrongly. WHEN & WHY Did/does this employer evaluate your job performance in writing? If so, what rating(s) did you receive? Have you ever received any awards or other special recognition from this employer? If so, describe the award or recognition and state the date on which you received it. If you are no longer with this employer, did you resign or were you fired?
If you were fired, state the reason given by your employer. If you resigned, state the reason you gave to your employer.
DESCRIPTION OF INCIDENT In the space provided below, please describe in your own words (and in detail) the events that have led you to believe that you were discriminated against or treated wrongfully by this employer/individual. Hidden In the space provided below, please describe in your own words (and in detail) the events that have led you to believe that you were discriminated against or treated wrongfully by this employer/individual (cont.) In the space provided below, please describe in your own words (and in detail) the events that have led you to believe that you were discriminated against or treated wrongfully by this employer/individual. Hidden In the space provided below, please describe in your own words (and in detail) the events that have led you to believe that you were discriminated against or treated wrongfully by this employer/individual (cont.) FOLLOW-UP QUESTIONS In your own opinion, WHY were you treated differently? Include names of people treated better than you. Include names of people treated better than you. Include co-workers who were treated more favorably and how they were treated better. NAME | GENDER | JOB TITLE | RACE | AGE | HOW
NAME | GENDER | JOB TITLE | RACE | AGE | HOW
Were you reprimanded (verbal, written, suspension, demotion, etc.) by this employer? If so, describe each incident of reprimand, including the date on which it occurred. Was/is your job performance or behavior criticized by this employer or any of your supervisors or coworkers? If so, describe each criticism in detail. Do you know if other employees who have committed or been accused of the same behavior as you who were treated differently by your employer (i.e. not reprimanded like you were)? If so, give complete details regarding each employee including name, date, and what the employee did. FOLLOW-UP QUESTIONS - EMPLOYMENT-RELATED ONLY (continued) Did you complete a job application and/or résumé for this employer? If so, was ALL information in that application or résumé truthful? If not, provide details or any other information that was inaccurate, incomplete, or untrue. Have you ever been reprimanded by any OTHER employer? If so, state the employer, date of reprimand, what you were reprimanded for, and any punishment you received. Have you ever been fired from any job, other than as described above? If so, provide complete details including the employer’s name, the date you were fired, and why you were fired. Have you ever been fired (above question) continued. What damages do you believe you have suffered as a result of what this employer did to you? Please be specific regarding wages you feel you have lost, money you have spent, mental or emotional injuries you believe you have received. If you no longer work with this employer, and if you included lost wages as part of your answer above, list all money you have made from any source since leaving this employer. OTHER GENERAL INFORMATION
Answer the following questions to the best of your ability.
If your answer to ANY of these questions is YES please explain below when prompted.
1. Have you previously hired or consulted with a lawyer concerning this problem? 2. Have you previously claimed that any person, business, or employer has discriminated against you? 3. Have you participated in grievance proceedings? 4. Have you ever filed internally with the EEO for this employer? 5. Have you ever filed a formal or informal claim of discrimination with regard to THIS employer with the FCHR or EEOC? If so, attach a copy of all documents filed or received from FCHR and EEOC. 6. Have you ever filed a formal or informal claim of discrimination with regard to ANY other employer with the FCHR or EEOC? 7. Have you ever filed a formal or informal claim of discrimination with any other administrative agency or any court? 8. Have you otherwise sued anyone or been sued by anyone (except divorces)? 9. Have you ever been diagnosed with a mental illness or disability? 10. Have you ever been hospitalized or confined for mental illness or disability? 11. Have you ever been adjudicated incompetent? 12. Do you suffer from serious physical illness or disability? 13. Are you currently taking any prescription medications? 14. Have you previously (during the period of your claim) taken prescription medication? 15. Do you regularly use drugs or alcohol? 16. Have you ever been treated for drug or alcohol abuse? 17. Have you ever been rendered totally or partially disabled? 18. Have you ever applied for disability compensation benefits? 19. Have you ever applied for or received unemployment compensation benefits? 20. Have you ever applied for or received workers’ compensation benefits? 21. Have you ever been arrested? 22. Have you ever been convicted of a felony or misdemeanor? 23. Are you receiving disability, social security, AFDC (food stamps or “welfare checks” or other social assistance? 24. Do you or did you have retirement benefits associated with your current or former job? 25. Have you ever served in the military? 26. Have you ever filed bankruptcy? 27. Do you have any plan or intention to file bankruptcy? 28. To your knowledge, have you received any bad or negative employment references from the employer that you believe discriminated against you? 29. Have you ever filed a complaint or grievance with regard to any lawyer who provided legal services to you? 30. Have you ever hired a lawyer to represent you and terminated the lawyer’s services before representation was complete? 31. During the period in which you claim you were discriminated against, were there any other stressful events in your life, such as births, deaths, divorces, marriages, significant problems with your children or family, criminal acts against you, etc.? 32. Have you received treatment by any medical or mental health professional as a result of the discrimination about which you are complaining? 33. Have you received treatment by any mental health professional concerning any matter other than the discrimination about which you are complaining? 34. Have you given any verbal, written, or recorded statements to any person regarding your discrimination/retaliation claim? 35. Have you ever been accused by any employer of dishonesty, such as theft or lying? 36. Have any of our lawyers at this firm represented you or anyone related to you? ANSWERS TO OTHER GENERAL INFORMATION QUESTIONS
If your answer to any of the previous questions is YES, please explain below with the Number of the Question first.
USE THIS SPACE to describe all persons that you believe have knowledge regarding your claim of discrimination. Include people you think will support you and people you think are against you.
Witness Type Witness 2 Witness Type Witness 3 Witness Type Witness 4 Witness Type Witness 5 Witness Type Witness 6 Witness Type Witness 7 Witness Type Witness 8 Witness Type Wintess 9 Witness Type Witness 10 Witness Type Witness 11 Witness Type Witness 12 Witness Type Important Document Information
Please list the name/info of the documents and who has it
Signature and Current Date