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do I have a case?
To help us evaluate your case please answer the following questions:
Were you a member of a union?
Yes
No
We're sorry, but we won't be able to assist you.
Were you employed in California?
Yes
No
We're sorry, but we won't be able to assist you.
How did your employment end?
Fired
Quit
Laid Off
Still Employed
What reason did the company use to fire you (even if it’s false)?
What do you thing is the REAL reason you were fired?
How many other employees were laid off with you?
Were you replaced after your layoff?
If you saw your job advertised after your layoff, where was it posted?
If you saw your job advertised after your layoff, where was it posted?
If you think you were singled out for layoff due to your age, race, complaints or some other unlawful criteria, please explain.
Were you forced to quit?
Why did you quit?
If your employer made the working conditions so unbearable that you had to quit, please describe.
Did you complain (either to an outside agency or to someone at work) about any workplace conduct that you thought was illegal or unethical?
Yes
No
On what date(s) did you complain?
Who did you complain to?
What did you complain about?
How did you complain (email, written, verbal)?
If your boss retaliated against you after you complained, please explain.
Were you fired while on medical leave (or about to take medical leave)?
Yes
No
When did your medical leave start?
What was the purpose of the medical leave?
How did your employer know about your medical leave?
Were you fired while pregnant?
Yes
No
When did you last miss a day of work due to your pregnancy?
How did your employer know that you were pregnant?
Do you have a disability?
Yes
No
What is your disability?
Did you require any special accommodations to do your job?
Did your employer know about your disability?
How did your employer know about your disability?
If your employer failed to accommodate your disability, please explain.
Were you sexually harassed?
Yes
No
Please describe the sexual harassment you experienced.
Who sexually harassed you (state their position as well)?
When were you last sexually harassed?
If you complained about the harassment, describe who you complained to, when you complained and what the company did to stop the sexual harassment.
Were your discriminated against due to your race, age, religion, gender or other protected class?
Yes
No
What evidence do you have that you were discriminated against?
Who discriminated against you?
What was done to you which made you feel discriminated against?
Were you ever disciplined at work?
Yes
No
What were you disciplined for?
On what date(s) were you disciplined?
What happened as a result (write-up, suspension, etc.)?
Did you work overtime (over 8 hours/day or over 40 hours/week)?
Yes
No
Were you paid a salary or hourly?
Did your employer pay you time-and-a-half if you worked over 8 hours per day?
Yes
No
Did your employer pay you time-and-a-half if you worked over 40 hours per week?
Did you ever work off the clock?
Yes
No
Did you get a 30-minute, uninterrupted meal break every day within the first 5 hours of work?
Yes
No
Why didn’t you get those meal breaks?
Did your boss know that you didn't get those meal breaks?
Yes
No
Did your employer interrupt you with work while on a rest break?
Yes
No
Did you get a 10-minute, uninterrupted rest break for every 4 hours of work?
Yes
No
Why didn’t you get those rest breaks?
Did your boss know that you didn’t get those rest breaks?
Did your employer bother you with work while you were on a rest break?
What was your date of hire?
On what date did your employment end?
What was your job title?
Please describe your job duties.
What was your rate of pay?
Name of your former employer?
How many employees does the company have?
How many employees at your work facility?
What county within California were you employed in?
How old are you?
Full Name
Home Phone
Cell Phone
Email
Please include any additional information that you feel is important to your case.
This form is being provided to help Eisenberg & Associates determine if you have any legal claims against your former employer. By filling out this form and sending it to us, no attorney-client relationship is created.
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