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February 04, 2012    

Do I have a discrimination or harassment claim against my employer?

Contact Information

Full Name
Email
Address1
Address2
City
State
Zip Code
Cell Phone
Home Phone
Birth Date
Race

Background Information

Prior Law Suits:

If Yes, please describe:

Have you ever alleged that you have been the victim of harassment or discrimination with this or any other employer:

If Yes, please describe:

Have you ever been terminated by an employer:

If Yes, please describe:

Claim Information

Name of Employer
Type of Business
Address1
Address2
City
State
Zip Code

Assigned Location

Address1
Address2
City
State
Zip Code
Briefly Describe Work Duties
Position/Title
Years Employed
Salary
Bonus

Work Records

When you were hired, or at anytime during employment were you given an employee handbook or documents describing rules and regulations:

If so, do you have these documents:

Were periodic evaluatWere periodic evaluations given to employees:

If so, were you given evaluations:

How were your evaluations:

Have you been written-up or been subject to any disciplinary action?

If so, please explain briefly:

Details of Allegations

Who is discrimination/harassing/retaliating against you? Does this person hold a supervisory position to you?

Briefly describe the discrimination/harassment/retaliation against you.

Why do you feel you are being targeted?

Have you reported the discrimination/harassment/retaliation to management or Human Resources? If so, what has been their response to your allegations?

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