Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Email * please use a personal e-mail only. No work e-mails accepted. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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City and State of your residence? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Who referred you? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Age {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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What is the name of the employer that you have a dispute with? required {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Current or last job title with this employer. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Location of where you currently work, or last worked for this employer (City and State)? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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If yes, when and how were they? (briefly describe) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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If yes, when and for what? (briefly describe) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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When did you START working for this employer? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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On what date did your employer inform you that you were being terminated? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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On what date did you resign? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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What reason did you give for your resignation? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Who told you that you were being fired (name, job title)? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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What reason were you given for your termination? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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If yes, briefly explain why. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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What was your last day of work? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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DISCRIMINATION, SEXUAL HARASSMENT AND RETALIATION:
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What law do you believe your employer violated or how do you believe your employer acted unlawfully? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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What illegal activity did you complain about? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Who did you complain to? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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What is your race / ethnicity or national origin? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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What is the race or national origin of the person that you allege is discriminating against you? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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What makes you think that your race / ethnicity or national origin played a role in your termination {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Were there any negative comments about your race or national origin? If yes what were the comments and who made them? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Are you aware of others who have been discriminated against of the same race or national origin? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Any are there any other details you would like to share about your termination or discrimination? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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What is your age? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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What is the approximate age of the person that you allege is discriminating against you? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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What makes you think that your age played a role in your termination {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Were there any negative comments about age or age-related comments? If yes what were the comments and who made them? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Are you aware of others who have been discriminated against due to their age? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Any are there any other details you would like to share about your termination or discrimination? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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What is your gender? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
What is the gender of the person that you allege is discriminating against you? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
What makes you think that your gender played a role in your termination {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Were there any negative comments about gender? If yes what were the comments and who made them? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Are you aware of others who have been discriminated against due to their gender? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Are you aware of others who have been discriminated against due to their gender? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Any are there any other details you would like to share about your termination or discrimination? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Describe the type of sexual harassment you experienced? (e.g. touching body parts, kissing, advances, comments, etc) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Was the person involved in the sexual harassment a supervisor or coworker? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Were there any witnesses? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Did you complain or inform management of the sexual harassment? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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What if anything happened after you complained? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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When did you inform your employer that you were pregnant? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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What makes you think that your pregnancy played a role in your termination? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Were there any negative comments about pregnancy or maternity leave? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Are you aware of others who have been discriminated against due to their pregnancy? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Any are there any other details you would like to share about your termination or discrimination? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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What is your disability? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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When did your employer learn of your disability? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
What makes you think that your disability played a role in your termination? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Were there any negative comments about yours or others disabilities? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Are you aware of others who have been discriminated against due to their disability? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Any are there any other details you would like to share about your termination or discrimination? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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What date did you request FMLA leave? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
What was the reason for the request for FMLA leave? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Who did you make your FMLA leave request to? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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How much leave was requested? (you can give dates, amount of time, ex. six weeks, or intermittent as needed”) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Was your request for leave approved? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Did you end up taking leave? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Any negative comments about you taking medical leave? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Are you aware of others who have been discriminated against due to taking medical leave? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Any are there any other details you would like to share about your termination or discrimination? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Was your employer aware of your sexual orientation? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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How are they aware? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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What makes you think that your sexual orientation played a role in your termination {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Were there any negative comments about your sexual orientation? If yes what were the comments and who made them? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Are you aware of others who have been discriminated against due to their sexual orientation? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Are there any other details you would like to share about your termination or discrimination? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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To whom did you make your complaints (name, job title)? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Date of complaint? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Did you specifically reference discrimination or sexual harassment in your complaint? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Was the complaint made verbally or in person? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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What specifically did you complain of? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
What response, if any, did you receive? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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What makes you think that your complaint played a role in your termination? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Any are there any other details you would like to share about your termination or discrimination? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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What is your religion or religious beliefs? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
When did your employer learn of your religion or religious beliefs? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
What makes you think that your religion or religious beliefs played a role in your termination? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Were there any negative comments about your religion or religious beliefs? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Are you aware of others who have been discriminated against due to their religion or religious beliefs? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Any are there any other details you would like to share about your termination or discrimination? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Date of injury? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Described how you were injured. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
When was your injury reported to your employer? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Did you seek medical attention? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Where you medical bills paid by the company’s workers compensation insurance? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
What makes you think that your injury or workers compensation claim played a role in your termination? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Were there any negative comments about your injury or workers compensation claim? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Are you aware of others who have been discriminated against due to their injuries or workers compensation claims? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Any are there any other details you would like to share about your termination or discrimination? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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I complained to HR or a supervisor about sexual harassment or discrimination
If Yes date of complaint: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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I made a complaint with the EEOC (Equal Employment Opportunity Commission)
If yes date of complaint with EEOC {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Briefly describe the complaint(s) made {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Type of discrimination alleged (e.g. race, age, pregnancy, gender, etc) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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If yes, state date of demotion, to what position, and difference in pay (if any) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
FAILURE TO PROMOTE
If yes state the date of application {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Position {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Difference in pay from current job {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Date you were informed of non-selection {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Total number of times you have applied for promotions and have been denied by this employer {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
Are there any other details you would like to share about your discrimination claim or termination? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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ABOUT YOUR POTENTIAL DAMAGES:
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How much were you paid with respect to your previous answer? (amount annualy, hourly etc.) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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If yes, date of new job {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Difference in hourly wage / salary with your old employer? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
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Disclaimer: Submitting information through this form does not create an attorney-client relationship. John A. Wenke, Attorney at Law, does not represent you unless/until you sign a representation contract with the office.
Signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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