The Feldman Law Firm
A PROFESSIONAL LAW CORPORATION

CONFIDENTIAL QUESTIONNAIRE

PLEASE NOTE:
WE ONLY HANDLE CLAIMS OF DISCRIMINATION AND/OR HARASSMENT BASED ON RACE, AGE, SEX, PREGNANCY, RELIGION, NATIONAL ORIGIN, SEXUAL ORIENTATION, DISABILITY (ADA), MEDICAL LEAVE OF ABSENCE, OR RETALIATION CASES WHERE YOU WERE FIRED FOR OPPOSING ANY OF THE ABOVE TYPES OF DISCRIMINATION OR HARASSMENT. THE ONLY OTHER EMPLOYMENT CASES WE HANDLE ARE THOSE WHERE YOU BELIEVE YOU WERE FIRED FOR REFUSING TO ENGAGE IN ILLEGAL ACTS, OR FOR REPORTING, PROTESTING OR COMPLAINING ABOUT UNLAWFUL ACTIVITY, UNPAID WAGES OR OVERTIME, UNSAFE WORK CONDITIONS, FRAUDULENT ACTIVITY. IF WE DECLINE TO TAKE YOUR CASE, IT DOES NOT MEAN YOU DO NOT HAVE ONE. THEREFORE, IF WE DECLINE YOUR CASE YOU SHOULD CONTACT ANOTHER ATTORNEY OR FILE A COMPLAINT WITH THE CALIFORNIA DEPARTMENT OF FAIR EMPLOYMENT AND HOUSING, WHICH YOU CAN CONTACT AT (213) 439-6799.
This questionnaire is meant solely for the use of the consulting attorney for purposes of analyzing and evaluating the prospective client’s case. The contents of this document are therefore protected by the attorney-client privilege and the attorney work product doctrine. It is very important that you be completely truthful, accurate and complete in answering the following questions. The defendant in this case will likely obtain all relevant records about you. Therefore, it is crucial that we are aware of all information, including information you may believe will damage your case, in order to best represent you.
  How did you find us?[ If on the Internet, please specify search engine and keywords used? If a Yellow Pages Book was used, please state the Geographic area of the book. If Personal Referral, please state the name of the referrer]
1. Your Name:
Home Phone:
Work Phone:
E-mail:
Address:
City:  St:  Zip:
2. Current Employer:
3. Date current employment obtained
4. You are seeking advice regarding your employment at:
      (If terminated, list former employer here) Empoyer’s Name:
5. Address of former employer:
6. What type of business is the employer (about whom you are seeking advise) in?
7. How many employees work in the company?
8. If you know, provide your best estimate as to the employer’s profitability or gross monthly or annual sales($):
A. GENERAL INFORMATION
1. When were you hired at that company that fired, harassed or discriminated against you?
2. When were you fired?
3. Your title when you were hired:
4. What is your current salary or the salary when you were terminated:
5. Your supervisor’s name and title:
6. Do you have a written employment contract?     YES     NO
7. Have you ever been told that you can only be fired for “good cause?”    YES     NO
Explain in detail what you were told and identify the person with whom you had the discussion:
8. Does the company have an employee handbook or manual that provides for progressive discipline?
    YES     NO     I don't know
9. Does the employee handbook or manual state that your employment is “at will” and that you may be fired for any reason?    YES     NO     I don't know
10. Have you signed a form stating that you agree to submit all disputes related to your employment to arbitration?
    YES     NO     I don't know
11. Are you a member of a Union?    YES     NO
12. Have you filed a grievance with your union regarding this problem?    YES     NO
B. NATURE OF DISPUTE
13. What is your complaint?
    Termination     Discrimination
  Forced Resignation     Harassment
  Demotion     Failure to Promote
  Suspension (disciplinary action short of termination)      Retaliation
  Other:
  Whistleblowing[check here if you feel that you were terminated, harassed, or demoted in part because you refused to violate the law, protested violations of law, protested unsafe work conditions, complained about non-payment of wages or overtime, or complained about discrimination or harassment of yourself or another employee. If you protested or opposed discrimination or harassment, please state the type of discrimination and/or harassment about which you were complaining: [SEX, GENDER, SEXUAL ORIENTATION, AGE, RACE, RELIGION, NATIONAL ORIGIN, MENTAL OR PHYSICAL DISABILITY, PREGNANCY, OR REQUESTING MEDICAL LEAVE]
 
14. If terminated, state what the Company said its reasons were for terminating you. (If you were told it was a layoff, state the reason the company gave for selecting you for layoff instead of other employees that hold the same or similar positions):
15. If terminated, please explain what you believe was the actual reason that the company terminated you. (If you believe the company truly reduced its workforce, and eliminated one or more positions, please explain why you think they chose you for layoff instead of other employees that hold the same or similar positions. In other words, we want to know what you think the motive was, not what the company told you its reasons were.)
16. If you were laid off, pursuant to a reduction in force, please list each employee that held a position similar to yours that was retained by the company when you were laid off. If your claim is discrimination based on age, race, gender, national origin, etc…, please also state the age, race, gender, or national origin of the employees that were retained. For each such employee, please also explain why you think that employee should have been laid off instead of you. For example, if you were laid off over an employee that had less seniority, less experience, less education or training, state that next to that employee’s name (BE SPECIFIC).
17. If your employer told you that it fired you for violating some company policy, or disciplinary rule, or regulation (e.g., absenteeism, tardiness, theft, timecard fraud, unsafe workplace conduct etc…), please list each and every other employee that you believe engaged in conduct of the same severity and frequency, but was not fired. If your claim is discrimination based on age, race, gender, national origin, etc…, please also state the age, race, gender, or national origin of the employees that were retained. If your claim is based on whistleblowing, please state whether the employees that were not disciplined as severely as you also engaged in whistleblowing. Also state what misconduct each of the listed employees actually engaged in, when, how frequently, and the name of any supervisors that knew the employee committed the misconduct that you contend was as severe as that for which you were fired.
18. Please list any supervisors or managers to whom you complained about discrimination, harassment or whistleblowing, including the dates of all such complaints. Be sure to state whether the complaints were oral or written and, if written, whether you have a copy.
19. Did your employer follow company policy and procedure in handling your dispute?    YES     NO     I don't know
20. Do you feel you were treated differently from other employees in similar circumstances?
    YES     NO     I don't know
If “yes”, please explain ”
21. Do you feel race, age, sex, national origin, religion, sexual orientation, medical condition, taking medical leave of absence, pregnancy, or disability (physical or mental) was the cause of this difference in treatment?
    YES     NO     I don't know
If so, why?
22. If you believe that any of the above-listed characteristics might have motivated the employment action taken, please describe in detail, each and every fact upon which you base that conclusion. Possible evidence may include the following:
(a) Statements or remarks by management: Examples of possible evidence of racial motive include, racial comments, stereotypes, jokes or comments by management, or comments by co-workers, of which management knew about. Also comments that you are not a “team player” might indicate a retaliatory motive.
(b) Others were treated more favorably in similar situations: If other employees who did not have your protected characteristic (were not of the same race, age, gender, or were not disabled), were in treated better in similar situations, that may show discriminatory motive. For example, if you are a woman and were fired for being late, the fact that other male employees were also late but were not fired, would constitute evidence of discrimination.
(c) Statistics: How many total employees at your company vs. how many employees of your gender, race, age or national origin. For example, if your company has only 2% Black employees, but 25% of the applicants are Black, that would tend to prove racism. Also, if Blacks, or women, or older workers make up only 10% of the workers at your company, but 50% of the terminations or suspensions, that would tend to support an inference that the terminations or suspension decisions were motivated by some protected characteristic.
23. List the name address and telephone number, if available, of any witnesses to incidents described above:
24. List the names of any other employees (current or former) who you believe have been treated like you?
25. Describe any documents that you believe support your case?
C. WORK PERFORMANCE
26. Was your work performance evaluated in writing? If so, please state the date of each evaluation and the overall rating you received. If please indicate whether you have copies of each evaluation.
27. Have you received any commendations, letters or memos telling you that you were doing a good Job?
28. Have your ever been disciplined, counseled, or warned about deficiencies in your work performance or violations of company policy at any time during your employment? If so, please state the date of each incident, the discipline imposed, the conduct for which you were disciplined and state whether you told your employer that you agreed or disagreed with the disciplinary action taken. Please provide all documents related to these incidents, including the write-up and memos, if they exist.
29. Have you ever been terminated or asked to resign from employment before?    YES     NO
If so, please describe, including the reasons given for your termination?
D. STEPS TO RESOLVE YOUR DISPUTE
30. Did you inform anyone in management of your complaint?    YES     NO
If so, state the date, name and title, of the person you informed and what actions were taken, if any, to resolve your complaint.
31. Does your company have an internal complaint procedure?    YES     NO
If so, did you file a complaint?    YES     NO
When?  
What was the result?
32. Have you filed a Union grievance?    YES     NO
What happened?
33. Have you filed a charge with the U.S. Equal Employment Opportunity Commission (EEOC)?    YES     NO
When?

What happened?
34. Have you filed a charge of discrimination, harassment or retaliation with the California Department of Fair Employment and Housing?    YES     NO
When?

What happened?
35. Do you have a copy of any charge filed with the EEOC or the Department of Fair Employment and Housing?
    YES     NO
If so, please attach copies.
36. Have you received a “Right to Sue” letter?     YES     NO
When?
37. If terminated, have you applied for unemployment benefits?    YES     NO
When?

Result?
38. Did anyone appeal the initial decision of the unemployment office?     YES     NO
If so, who appealed?
39. Have you examined your personnel file?     YES     NO
If so, briefly state any fact of importance contained in or missing from your personnel file:
E. FINANCIAL AND EMOTIONAL EFFECTS OF THE DISPUTE
40. Describe the effect of your discharge or other action taken against you by your employer on your income; medical or pension benefits; profit sharing; or other financial impact:
41. Describe the effects of your discharge or other action taken against you by your employer on your health and/or personal life, family relations, and opportunities for other employment?
42. Have you sought any medical treatment or counseling because of your employment problems?    YES     NO
If so, describe:
A.] Identify which of the emotional problems you now have that you had before the incident that caused you to seek legal counsel. In other words, which problems did you have before the harassment or discrimination even took place. Be sure to think carefully about this question because the defendant will subpoena all records from doctors, therapists or psychiatrists to determine whether you already had any or all problems you claim were caused by the defendant. F. PRIOR CIVIL OR CRIMINAL LITIGATION OR CLAIMS 39. Have you ever complained to any employer, formally or informally, orally or in writing, about harassment or discrimination, or filed any other discrimination complaint against this employer or any other previous employer, with either the company or the EEOC of the Department of Fair Employment and Housing? If so, please describe the nature of the complaint and how it was resolved.
F. PRIOR CIVIL OR CRIMINAL LITIGATION OR CLAIMS
43. Have you ever complained to any employer, formally or informally, orally or in writing, about harassment or discrimination, or filed any other discrimination complaint against this employer or any other previous employer, with either the company or the EEOC of the Department of Fair Employment and Housing?    YES     NO
If so, please describe the nature of the complaint and how it was resolved.
44. Have you ever filed a lawsuit before or have you ever been sued before?    YES     NO
If so, please explain:
45. Have you ever filed for bankruptcy before, or are you considering filing bankruptcy in the near future?    YES     NO
If so, please state the date you filed and the result, (or state the date you are planning on filing bankruptcy. (****Note – if you are planning on filing bankruptcy anytime soon do not sign or file any bankruptcy documents without consulting with this office first, as filing a bankruptcy action could result in the termination of your lawsuit****)
46. Have you ever been arrested?    YES     NO
If so, please state the date, the charge/s and whether you were convicted.
47. Have you ever filed a worker’s compensation claim for any injuries sustained at work?     YES     NO
If so, state the date of complaint and the result?
48. Since your termination, have you looked for other employment?     YES     NO
If so, please describe your efforts, including dates, the name of the employer from whom you sought employment, and what the result?