Step 1 of 8 - Personal Information 12% Preliminary Assessment Questionnaire for Employment Claims Only Your submitting this form does not bind you to retain us, nor does it bind us to represent you. You are providing this information simply to help us determine if we may be of assistance to you. If we agree to represent you, we will advise you expressly and enter into a written agreement with you. Until that time, you retain the obligation to safeguard whatever claims you may have, including guarding against the expiration of any applicable statutory period of limitations. This form provides no legal advice whatsoever. The information you provide will be maintained in confidence by this firm. 1. Personal InformationName* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Cell Phone*Personal Email*Date of Birth*Gender*FMAre you able to work?* Yes No Explanation for not being able to work 2. Your employer or former employerPlease provide basic information about your employer. (If you are no longer employed at the place where the discrimination or harassment occurred, please provide information about where you were employed at the time.)Company or agency where you were employed*Address of Employer or Former Employer* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Type of Business*Approximate number of employees* 3. Your dealings with the employerYour position on the job (actual or desired)*Starting date of employment with, or application for employment by, the employer:*Date of termination (if applicable)Do you have an employment contract?* Yes No If yes, please bring a copy with you to your first meeting with Victor M. Glasberg & Associates. Have you been offered a severance agreement?* Yes No If yes, please bring a copy with you to your first meeting with Victor M. Glasberg & Associates. Earliest date of unfairness of which you complain* MM slash DD slash YYYY Most recent date of unfairness of which you complain* MM slash DD slash YYYY Have you filed a charge of discrimination with a government agency?* Yes No If yes, which agency?If yes, please bring a copy with you to your first meeting with Victor M. Glasberg & Associates. 4. Basis of Claim If you believe that you were unfairly treated based on any of the following, please indicate by checking the appropriate category, and describe yourself accordingly.Gender Female Male Pregnancy - estimated or actual date of deliveryRace or colorNational origin or languageReligionAge - state age at relevant timeDisability - diagnosed disabilityOther - please explain 5. Link between unfairness and characteristics that give rise to claim Please state why you believe that the reason for which you were unfairly treated is because of your characteristics indicated by your response to question #4. What is needed here is not an itemization of unfairness, but an itemization of how and why you connect that unfairness with your characteristics that you believe give rise to your claim.Your statement about the link between unfairness and characteristics 6. Retaliation for protected activity. If you believe that you were retaliated against for having complained or supported a complaint of discrimination or harassment ("protected activity"), state the following:Date of protected activityNature of protected activityDate of RetaliationNature of retaliationDo you have evidence that the retaliator knew of your protected activity? Yes No If yes, please bring a copy with you to your first meeting with Victor M. Glasberg & Associates. 7. Retaliation If you are claiming retaliation, please state why you believe that the employer's actions at issue were taken because of your protected activity. What is needed here is not an itemization of unfair acts, but an itemization of how and why you connect those unfair acts with your protected activity.Your statement about retaliation 8. Harrassment If you believe you were the victim of harassment on the job, please answer the following questions.Harrasser's nameHarrasser's job titleDoes your employer have a policy regarding harrassment? Yes No If yes, please bring a copy with you to your first meeting with Victor M. Glasberg & Associates.Harrasser's roleSupervisorPeerSubordinateYour statement about harassmentDid you submit a written complaint of the harassment? Yes No If yes, please bring a copy with you to your first meeting with Victor M. Glasberg & Associates. Statement about motivation for harassmentEmailThis field is for validation purposes and should be left unchanged. Δ
