(PLEASE PRINT -- USE CONTINUATION SHEETS IF NECESSARY)

 

EMPLOYMENT QUESTIONNAIRE

 

  1. Name: __________________                Date: _____________

 

  2. Address: _____________________________

 

  3. City: ______________    State:_____   Zip code: _______

 

  4. Home phone: ________________  Work phone: _______________ 

 

     Work hours:  ____________________________________________

 

  5. Name of present employer (if any): _____________________

 

  6. Type of business: _______________________________

 

7.     Date started: ____________________ Position: _________________  

 

  8. Person to contact if you cannot be reached:

     Name: ______________    Phone: ________________________________

 

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

I WISH TO COMPLAIN AGAINST:

 

  9. Name of employer: __________________________

 

 10. Address where you worked: ________________________

 

     City: _____________________ Zip code: _______  Phone: ____________

 

 11. Address of corporate headquarters: ___________________________

 

     City ________________________ Zip code _______________________

 

     Telephone Number _____________________________________________

 

 12. Describe employer’s business and how your job fits into it;

 

 

 

 13. How many employees work in the entire company? ___

 

 14. How many employees work where you worked? ___

 

 

15.     How long have you worked at the company? ___________________

   

16. What date did you begin there and what was your first     position? _____________________________________________________

 

 17. What date did you stop working at this company? _____________

 

18. What was the last position you held with the company? ____________________________________________________

If not clear from the title, what exactly did you do at the company? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

19. Did the employer promise or suggest anything about job security when you were hired?  If so, explain.  ______________________________________________________________________________________________________________________________________

 

 20. Did you have a written contract of employment with this   company? ______ If so, is a copy attached? _____ 

 

 21. When you were first hired, were you given any paper or letter      confirming your hiring? __ If so, is a copy attached? ___

 

22. Were any promises made when you were hired that you believe were not genuine? Yes If so, which ones, who made the promises and why do you believe they were not genuine? _________________________________________________________________________________________________________________________________________________________________________________________________________

 

 23. How many promotions did you receive at this employer? __

 

 24. For each position you held at this employer, please state the name of the position and the inclusive dates of holding same.

     ___________________________________________________________________

     ___________________________________________________________________

 

 25. What was your starting salary or wage or annual earnings at   this employer?  (If you were paid on a commission basis, state     your annual earnings) $ _______________

 

 26. How many raises did you earn at this company? __     Were any of these merit raises? __ How many? __

 

 27. What was your last salary or wage or annual earnings at this

     employer? (If you were paid on a commission basis, state your annual earnings) $________ per Week/Month/Year (circle one)

 

28.     Did you ever receive a monetary bonus at this company? __   

If so, when, how much and for what?  ____________

 

 29. Did you ever receive an employee handbook? ___ If not,

     does this employer have such a handbook? ____  Have you

     obtained a copy? ____ Is the copy enclosed with this      questionnaire? ____

 30. Were you ever asked to sign either an addition or an addendum or a modification to the employee handbook? _____

If so, when? ____  Do you have a copy of the addendum,etc.? ____  Is it enclosed with this   questionnaire? _____

 

 31. Does the company give performance evaluations? ____ If so,are the evaluations oral? ____ written? ____ both? ____   

If written, do you have copies? ____ Are they enclosed? ____

 

 32. How have your performance evaluations been (i.e., good,   average, or whatever)? _____

 33. Did you ever receive anything in writing which said you were doing or had done a good job? ____ If so, what did you     receive, when did you receive it, who sent it and what did it    say? ____

 

34. Did anyone ever tell you that you had done or were doing a good job? ____ If so, who told you, what was said and when? __________________________________________________________________

    __________________________________________________________________

 

35. On behalf of the company, did you ever train or help to train others?  __ If so, who, when,and for what position(s)? _________________________________________________________________

 

36. Did you ever attend trade or professional or industry meetings on behalf of the company? __ If so, when, what groups and where? ______________________________________________________________________________________________________________________________________

 

 37. Were you ever written up favorably in either a company    newsletter, association newsletter, or public newspaper? _____

If so when, what publication and for what? ______________________________________________________________________________________________________________________________________

 

38. In your last position with the company, how many people did you supervise? ___ Of that number, how many people are still with the company? __

 

39. Is there anything else that led you to believe, during the    term of your employment, that you had job security? __ If    so, please explain _________________________________________________

 

40. Name and title of your last supervisor? _______________________

 

 41. When did this person become your supervisor? __________________

     Had you ever worked with this person before they became your      supervisor? ____ If so, when and in what capacity? ____________

 

 42. What were the names and titles of your previous supervisors?

     _______________________________________________________________

 

 43. At the time of your termination, how was the company doing      financially, if you know?  _______________

     If the company was not doing well, state what factors were      responsible for this ________

 

 44. For the most recent calendar year, state your ex-employer’s: 

     Annual sales: $_______________  Net worth $____________  

Assets: $___________________

    

 45. Do you have copies of any of your company’s annual reports for      the last five years? ___ If so, are they enclosed? ____

 

46. Is the company traded on any stock exchange? ____ If so, what stock exchange? _____

 

47. At or around the time of your termination, were any other employees terminated? ___ If so, please state the    names, job titles, and approximate dates of other persons who were terminated __________________________________________________________________

 

48.  In the last three years that you were with the company,      approximately how many times have layoffs occurred? _______

 

49.     On this job, were you ever suspended? ____ Put on Probation? ____

Given any warnings? _____

     If yes to any of the above, please explain, giving dates, who gave the warning, suspension etc., and for what? ______

 

50.     When did you first learn that things were not going well on the job? ______________________________

 

 

51. How did you first learn that things were not going well on    the job?  __________________________________________________________

 

 

52. What did you do to correct the situation? __________________________________________________________________

 

53. Before you were terminated, were you told specifically that your job was in danger? _____________ If so, when, by whom, exactly    what was said, and was anyone else present? ________

 

 54. Before you were terminated, did you ever make any complaint to      higher management, the government, or make any attempt to      straighten out the problems? ____

     If so, to whom did you speak, when, what did you say and what was the outcome? _____

    

 

 55. If you did not complain, please state why you did not     complain.     _____

 

 56. Does the company have a grievance or complaint procedure? ___

If so, did you file a grievance or complaint? ___ If you did, when to whom and what happened? ____

 

 57. Were you fired (note - the word "fired" here includes firing, layoff, reduction in force, termination or any similar word)?

     ____

 

 58. What is the name and job title of each person who notified you      that you were being fired? ____

 

 

 59. On what date were you notified that you were to be fired? ___

         

When was your termination to be effective? ____

 

When did your termination actually become effective? ____

 

 60. State the names and job titles of each person present at the time you were told that you were being fired. ____

 

State the name(s) and job title(s) of the person(s) you believe made the decision to fire you. _____

 

    

 61. Where were you when you were told you were being fired? ____

 

 

62. Were you forced to resign or quit? ____

    If so, answer the next four questions. If no, skip to question 67.

 

 63. When did you notify the company you were resigning? __________

     When was your resignation to become effective? _______________

     When did your resignation actually become effective? _________

 

 64. Did you give written notice of your resignation? _____________

     If so, is a copy enclosed? ______________ To whom did you give

     this notice? _____________________ Did that person respond in

     any way? ________________ If so, what did that person say or do? __________________________________________________________

 

     ______________________________________________________________

 

 65. Who (name and title) forced you to resign? ___________________

 

     ______________________________________________________________

 

 66. What circumstances forced you to resign? _____________________

 

     ______________________________________________________________

 

67. What was the reason given by your employer for your termination?  ____

 

 

68. Name and title of the person(s) who gave you this reason ___

 

 

69. What do you think was the real reason for your termination? ___

 

 

70. Exactly what facts led you to believe that this was the real reason? ___

 

 

 71. Do you believe that you were discriminated against by your      employer on the basis of (check and complete as many as   applicable)

    

     a. ___ Race.  If so, what is your race? ____________________

 

     b. ___ Age.   If so, what is your age? _____________________

 

     c. ___ National Origin.  If so, what is your National Origin?                         _____________________________________

 

     d. ___ Religion.  If so, what is your religion? ______________

 

     e. ___ Physical Handicap. If so, what is your handicap? ______

 

     f. ___ Marital Status.  If so, what is your marital status.

                             _____________________________________

 

     g. ___ Sex.  If so, what is your sex? ________________________

 

     h. ___ pregnancy.

 

i. X   Other discrimination (specify your category) __________________________________________________________________

      

72. Exactly what facts in detail, led you to believe that there was discrimination against you (give names, dates, facts and events)? ______________________________________________________________________________________________________________________________________

 

 

73. How would you show or prove a connection between any of the categories you checked in question 71 above and the decision To terminate you? Be very specific, giving details of persons, facts, dates and events. _________________________________________________________________________________________________________________________________________________________________________________________________________

 

74. If you checked any of the discrimination categories in question 71 above, please answer this question.  Have you Filed a complaint with:

    

EEOC (Equal Employment Opportunity Commission)? ___When? ____

Case No.  ____________      Is a copy of your complaint enclosed with this questionnaire? ___

    

     DFEH (Department of Fair Employment and Housing)? ____

When? ____ Case No. ______________ Is a copy of your complaint enclosed with this questionnaire? ____

 

Have you received a right-to-sue letter from either the EEOC or the DFEH? ____ If so, from which agency and when is the

letter dated? ____  Have you enclosed a    copy of all right-to-sue letters you have received with this questionnaire? _____ 

  

 75. Did you refuse to perform an illegal or unethical or unfair act in connection with your employment? ____ If so,what were you ordered to do, when and by whom? ______________________________________________________________________________________________________________________________________

 

 76. Did you report any misconduct or illegal conduct of the   employer to either management or the public authorities? If      so, what did you report, to whom and when? ______

 

 77. Does this employer have written personnel policies? ____

 

78.     Does this employer have a written list of rules and regulations?

_____

 

79. In discharging you, did the employer violate any of its policies,  rules or regulations? _____  If so, please explain which one(s) and how? ____ 

 

 80. On this job were you a member of a union?  ___ If so,

     what is the name of the union and the local? _____ 

 

 81. Since your termination, have you talked to anyone who still   works at the company? ____  If so, give complete details

     (who, when, who said what, etc.) ________________________________ 

 

 82. Since your termination, has there been any written   communication between you and anyone who still works at the   company? ___  If so, give complete details (who, what,

     when) and attach copies of any letters: ___ 

 

83. Since your termination, have you told anyone that you were thinking about taking any legal action against the company? If so, who, when, and what did you say? _____ 

 

84. Since your termination, has any lawyer called or written or contacted     the company in any way on your behalf? N/A      if so, when and what and what was said or written (enclose

     copies)? N/A 

 

85. Do you have friends at the company that you believe would offer favorable testimony to support your claims? ____     If yes, state their name(s), address and telephone number and provide a brief summary of what they will say.  (Please attach

     separate sheet of paper for each and label witness and    statement.)    

 

86. Are there people you believe would offer negative testimony? ___   If yes, please state their name(s) and what you believe they will say:

______________________________________________________________________________________________________________________________________

 

87. What do you feel were your strengths as an employee? ______________________________________________________________________________________________________________________________________

 

 88. What will the employer say your strengths were as an employee?

______________________________________________________________________________________________________________________________________

    

89. What were your weaknesses as an employee? _________________________________________________________

_________________________________________________________

 

 

90. What will the employer say were your weaknesses as an employee? ______________________________________________________________________________________________________________________________________

 

91. Did you receive or will you be receiving any severance pay    from this company? ___ If so, how much did or will you get in total? ___ If you did not receive     any severance pay, did the company offer you any severance pay? __ If so, how much did the company offer? __   Where you given any papers in connection with getting severance pay from the company? __  Did you sign any such papers? __ Do those papers contain a release of any claims? __  Have you enclosed copies of those papers? __ (Note - we must have copies of any papers you signed or were given in connection with severance pay.)

 

 92. Have you ever filed any case or charges or made any claims against this employer (other than anything stated above in this questionnaire)?  ___  If so, give complete details (date(s), what the controversy was, type of claim, etc.) ______________________________________________________________________________________________________________________________________

 

93.  Have you ever filed any case or charges against any employer other than the employer against whom you are complaining here?

If so, give complete details (company, dates, outcome, etc.) ______________________________________________________________________________________________________________________________________

 

 

 

94.  Have you ever been involved in any other legal dispute,   insurance claim, accident claim, lawsuit, or something similar

     not described above? ___ If so, please give details:

    

    

 

 95. Have you ever been convicted of any felony, including fraud   and/or perjury? ___ If yes, list case number and dates:

 

96. Have you ever testified as a witness in a court, deposition, or other hearing or legal proceeding? ___

     If so, give complete details (when, where, your role and the

     subject of your testimony, etc.) _____________________________

 

     ______________________________________________________________

 

     ______________________________________________________________

 

     ______________________________________________________________

 

97.    Have you ever assisted or worked with any attorneys who represented any of your employers?  __ If so, give complete details (company, law firm, individual attorneys, your role, what you did, etc.) ______

 

98.    What law firms represent or have represented the company against 

     which you wish to complain? ___

 

 99. Have any other ex-employees ever sued the company? ____________      (Note - Do NOT count workers compensation cases) If so, give

     details (names, what the suit was about, outcome, etc.)

     _________________________________________________________________

 

    

100. During your last year of employment and from termination to   the present, has any employee or ex-employee told you that    he/she

is or was going to sue the company?  ___  If so,

     give details (names, what the suit was about, outcome, etc.)

    

101. How long have you been (or were you) out of work? ____

 

102. Have you become re-employed since your left this job? ____

     If so, at what company, when, what job or title and what salary?

 

103. What have you done since your termination to try to find work?

     ____

 

104. At what companies have you had interviews? ______________

 

    

 

105. At any of these companies, have you discussed any of the facts     of your termination with the interviewer? ____ If so,give details date, company, interviewer, what was said, etc.)_________________________________________________________

 

106. How has your former employer responded to reference requests? ____ How do you know or why do you think so? _____________________

 

107. Do you have any evidence that your ex-employer is attempting to prevent you from finding work? ____ If so, explain what it is and how you learned it: ______________________________________________

 

108. What has been your wage loss to date? ____________________________

     How do you calculate this amount?  (Be specific - show your

     calculations in detail including dates when you were completely unemployed and dates, if applicable, after you went back to work)

 

109. Describe each and every financial loss (besides loss of salary) which was caused by your termination, giving type of loss, amounts, etc. _____________________________________________________________

 

110. What other types of harm or loss has your termination caused you or your family? ______________________________________________

    

111. Have you sought and treatment or counseling as a result of    your termination? _____ If so, when, who did you consult

     and for what reason did you consult them? ____________________

 

     ______________________________________________________________

 

112. Have you spoken to any other lawyer about this case? _____ If so, for each lawyer, please provide name and phone number: ______________________________________________________________________________________________________________________________________

 

113. Have you retained and/or discharged any lawyer regarding this case? ___  If yes, for each lawyer, please provide their name and phone number: ___________________________________________________________

114.    Did you apply for unemployment insurance benefits? ____

  When? _____ Did you receive the benefits? _____

     Did your employer oppose your application for benefits? ______

     Did anyone appeal the initial decision of the unemployment    office? _____ If so, who?  ____ Was a hearing held before a judge? _____

     When? ____    Has their been a decision? _____  In whose favor? ________

     Have you obtained a transcript of the hearing? ______

     If so, have you enclosed a copy of the transcript? ______

     If you have a copy of a decision, have you enclosed it? ______

    

115. What is your present marital status? _________

 

116. Are you responsible for the care of any children or other family members? ____ If so, who and what ages? ______

 

117. With whom do you live (name(s) and relationship: ________________ 

118. Have you discussed your claims against your employer with your family members, spouse, or friends?  Yes If so, what was that person’s opinion? ___________________________________________________________________Did that person recommend anything for you to do? ______ If so, what? ________________

 

119. Add any other information you think is pertinent. (Use    additional pages if necessary. WRITE ON ONE SIDE OF THE PAPER   ONLY) ________________________________________________________

 

             

PLEASE READ CAREFULLY AND DATE AND SIGN BELOW

 

I am submitting the above and enclosed for your review and related analysis of my case.  I understand that (1) The submission of the information in this questionnaire and other information submitted is for your review and analysis to prepare a demand for the purpose of settlement of my claims against my employer; (2) The retainer agreement I signed is limited only to pre-litigation efforts toward settlement of my claims; (3) You have not made any decision on whether or not you would accept my case for litigation; (4) Further information from me may be necessary in order for you to effectively pursue settlement of my claims and to make any decision, should settlement negotiations fail, to accept my case for litigation; (5) You will not litigate my case unless you and I have entered into a separate written retainer agreement for the purpose of litigating my claims.

 

I certify that the information contained in this questionnaire and any attachments hereto are true to the best of my knowledge and belief.

 

 

DATED: _______________________   _________________________________

                                      (Signature)