Case Evaluation Questionnaire

John Wenke Attorney at Law Consultation
Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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City and State of your residence? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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How did you find us? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Gender {{ 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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Did you receive any performance evaluations in the last 3 years? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Did you receive any disciplinary actions or write ups in the last 3 years? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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ABOUT YOUR EMPLOYMENT:

 

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Does the company have more than 15 employees nationwide? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Were you classified as an employee, or an independent contractor? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Hint: Employees typically receive W2's each year, and have taxes withheld from their paychecks. Independent Contractors typically receive 1099's, and do not have taxes withheld from their paychecks.

Did you sign an employment contract with this employer? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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During your employment, did you sign an "Arbitration Agreement" or "Alternative Dispute Resolution" agreement? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Do you still work for this employer? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Were you terminated or did you resign? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Did your employer offer an explanation verbally or in writing as to why they were firing you? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Do you disagree with the reason your employer gave for terminating you? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Did you receive a termination letter? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Were you offered severance? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Did you sign a severance agreement? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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DISCRIMINATION, SEXUAL HARASSMENT AND RETALIATION:

 

Do you believe your employer fired you because of any of the following factors? Check all that apply: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Was the complaint verbal, written or both? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Did you complain to a law enforcement agency? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Does your employer have more than 50 employees in the city where you are employed? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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I complained to HR or a supervisor about sexual harassment or discrimination

I complained to HR or a supervisor about sexual harassment or discrimination {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Was the complaint verbal, in writing or both? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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I made a complaint with the EEOC (Equal Employment Opportunity Commission)

I made a complaint with the EEOC (Equal Employment Opportunity Commission) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Type of discrimination alleged (e.g. race, age, pregnancy, gender, etc

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DEMOTION

Have you been demoted in the past 6 months as a result of the discrimination or retaliation you have described above? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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FAILURE TO PROMOTE

Have you been denied a promotion in the past 6 months as a result of the discrimination or retaliation you have described above? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Did you take any company documents (including emails) or company property with you when you left? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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ABOUT YOUR POTENTIAL DAMAGES:

As of the date of your last day of work, how were you paid? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Have you applied for unemployment benefits since your termination? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Was your unemployment application granted? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Have you obtained a new job yet? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Since you were fired, have you filed any applications for social security, or other disability benefits? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Since you were fired, have you filed for bankruptcy protection? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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FINAL QUESTIONS:

Have you already initiated any type of legal proceeding? Check all that apply: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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How many times in your life have you been involuntarily fired or let go from a job? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Have you previously had any legal disputes with other employers? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Have you ever been a party to a lawsuit before? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Have you ever testified in court, or in a deposition? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Have you ever been convicted of any crime (other than a minor traffic violation)? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Are you currently facing any criminal charges? {{ Cognito.resources["required-asterisk"] }} , { 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.

 

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Case Evaluation Questionnaire

Case Evaluation Questionnaire

John Wenke Attorney at Law Consultation
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 }
{binding displayValue}
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City and State of your residence? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
How did you find us? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Who referred you? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Age {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Gender {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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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 }
{binding displayValue}
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Current or last job title with this employer. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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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 }
{binding displayValue}
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Did you receive any performance evaluations in the last 3 years? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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If yes, when and how were they? (briefly describe) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Did you receive any disciplinary actions or write ups in the last 3 years? {{ 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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ABOUT YOUR EMPLOYMENT:

 

When did you START working for this employer? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Does the company have more than 15 employees nationwide? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Were you classified as an employee, or an independent contractor? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Did you sign an employment contract with this employer? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
During your employment, did you sign an "Arbitration Agreement" or "Alternative Dispute Resolution" agreement? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Do you still work for this employer? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Were you terminated or did you resign? {{ 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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Did your employer offer an explanation verbally or in writing as to why they were firing you? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Do you disagree with the reason your employer gave for terminating you? {{ 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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Did you receive a termination letter? {{ 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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Were you offered severance? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Did you sign a severance agreement? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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DISCRIMINATION, SEXUAL HARASSMENT AND RETALIATION:

 

Do you believe your employer fired you because of any of the following factors? Check all that apply: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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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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Was the complaint verbal, written or both? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Who did you complain to? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Did you complain to a law enforcement agency? {{ 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 }
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What is the gender 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 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 }
{binding displayValue}
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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 }
{binding displayValue}
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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 }
{binding displayValue}
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Were there any negative comments about pregnancy or maternity leave? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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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 }
{binding displayValue}
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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 }
{binding displayValue}
{ binding firstError.message }
What is your disability? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
When did your employer learn of your disability? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
What makes you think that your disability played a role in your termination? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Were there any negative comments about yours or others disabilities? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Are you aware of others who have been discriminated against due to their disability? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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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 }
{binding displayValue}
{ binding firstError.message }
Does your employer have more than 50 employees in the city where you are employed? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
What date did you request FMLA leave? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
What was the reason for the request for FMLA leave? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Who did you make your FMLA leave request to? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
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 }
{binding displayValue}
{ binding firstError.message }
Did you end up taking leave? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Any negative comments about you taking medical leave? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Are you aware of others who have been discriminated against due to taking medical leave? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ 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 displayValue}
{ binding firstError.message }
Was your employer aware of your sexual orientation? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
How are they aware? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
What makes you think that your sexual orientation played a role in your termination {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ 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 }
{binding displayValue}
{ binding firstError.message }
Are you aware of others who have been discriminated against due to their sexual orientation? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Are there any other details you would like to share about your termination or discrimination? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
To whom did you make your complaints (name, job title)? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Date of complaint? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Did you specifically reference discrimination or sexual harassment in your complaint? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Was the complaint made verbally or in person? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
What specifically did you complain of? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
What response, if any, did you receive? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
What makes you think that your complaint played a role in your termination? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ 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 displayValue}
{ binding firstError.message }
What is your religion or religious beliefs? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
When did your employer learn of your religion or religious beliefs? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ 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 }
{binding displayValue}
{ binding firstError.message }
Were there any negative comments about your religion or religious beliefs? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
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 displayValue}
{ 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 displayValue}
{ binding firstError.message }
Date of injury? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Described how you were injured. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
When was your injury reported to your employer? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Did you seek medical attention? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Where you medical bills paid by the company’s workers compensation insurance? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ 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 }
{binding displayValue}
{ binding firstError.message }
Were there any negative comments about your injury or workers compensation claim? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
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 }
{binding displayValue}
{ 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 displayValue}
{ binding firstError.message }

I complained to HR or a supervisor about sexual harassment or discrimination

I complained to HR or a supervisor about sexual harassment or discrimination {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
If Yes date of complaint: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Was the complaint verbal, in writing or both? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
{ binding firstError.message }

I made a complaint with the EEOC (Equal Employment Opportunity Commission)

I made a complaint with the EEOC (Equal Employment Opportunity Commission) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
If yes date of complaint with EEOC {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Briefly describe the complaint(s) made {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Type of discrimination alleged (e.g. race, age, pregnancy, gender, etc) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

DEMOTION

Have you been demoted in the past 6 months as a result of the discrimination or retaliation you have described above? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
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

Have you been denied a promotion in the past 6 months as a result of the discrimination or retaliation you have described above? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
If yes state the date of application {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Position {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Difference in pay from current job {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Date you were informed of non-selection {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ 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 displayValue}
{ binding firstError.message }
{ binding firstError.message }
Did you take any company documents (including emails) or company property with you when you left? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ 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 }
{ binding firstError.message }

ABOUT YOUR POTENTIAL DAMAGES:

As of the date of your last day of work, how were you paid? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
How much were you paid with respect to your previous answer? (amount annualy, hourly etc.) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Have you applied for unemployment benefits since your termination? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Was your unemployment application granted? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Have you obtained a new job yet? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
If yes, date of new job {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Difference in hourly wage / salary with your old employer? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Since you were fired, have you filed any applications for social security, or other disability benefits? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Since you were fired, have you filed for bankruptcy protection? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
{ binding firstError.message }

FINAL QUESTIONS:

Have you already initiated any type of legal proceeding? Check all that apply: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
How many times in your life have you been involuntarily fired or let go from a job? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Have you previously had any legal disputes with other employers? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Have you ever been a party to a lawsuit before? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Have you ever testified in court, or in a deposition? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Have you ever been convicted of any crime (other than a minor traffic violation)? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Are you currently facing any criminal charges? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

 

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 }
{ binding firstError.message }