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Contact Information
First Name
Last Name
Phone
Email
What State do you reside in?
Is this about a job or workplace?
Yes
No
Not Sure
It sounds like this may not be about your own workplace. We focus on employees wronged at work. We'll still point you to resources that fit better.
This is the kind of matter we evaluate. Let's gather a few more minutes of detail now so an attorney can review it.
What was your connection to the employer?
I work/worked there
I applied for a job there
Intern or Volunteer
Independent Contractor
I am reaching out for someone else
Your Potential Case
What is this about?
Injured at Work
Injured in a car accident
Injured by someone else - not at work
Medical Malpractice
Dangerous or Defective Product
Police Conduct or Excessive Force
Criminal Charges
Housing or Eviction
Family or Custody
Consumer or Debt
Immigration, not job-related
Something else
Injury Details
When did this injury happen? (MM/DD/YYYY)
Have you seen a doctor about it?
Yes
No
Not Yet
Do you already have a lawyer for this issue?
Yes
No
Not Sure
Briefly, what happened?
Did anything happen to your job after the injury?
Fired / Terminated
Demoted
Suspended
Put on unpaid leave
Hours or pay cut
My job was posted or filled
Nothing yet
Did you ask for any change at work because of the injury?
Yes
No
Not Sure
Your Job
What is the Employers Name?
Is your employer a government/public-sector entity or a private employer?
Federal Government
State | County | City Government
Private Employer
What State is the Employer Located In?
What was your job title?
Date your employment started
(MM/DD/YYYY)
Are you still working there?
Yes, still working there.
No longer working there
On leave right now
Suspended
Last Date You Worked
(MM/DD/YYYY)
How are you paid?
Hourly
Salary
Hourly plus bonuses-commissions
Hourly plus Tips
Hourly & Mileage
Commission
Salary plus bonuses-commissions
Other
Your Annual Pay / Salary (Estimated)
Under $50,000
$50,000 - $74,999
$75,000 - $99,999
$100,000 - $149,999
$150,000 - $249,999
$250,000 - $499,999
$500,000+
Your Hourly Rate
Are there any issues with pay or overtime?
Roughly how many people work there?
What Happened?
What is this about?
Harassment or Hostile Work Environment
Discrimination
Illness, Disability, Injury or Pregnancy
A pay or hours problem
Something else
Choose all that apply
What has happened?
Fired or Terminated
Laid off
Demoted
Denied a promotion
Denied a raise
Pay or hours cut
Forced to resign
Sexual comments, jokes, or images
Unwanted touching
Comments about a characteristic
Not paid for hours or overtime
Denied time off or accommodation
Worried about being terminated
Choose all that apply
What is the reason the employer gave for its decision?
What do you believe is the real reason?
Do you believe that discrimination is the real reason?
Yes
No
Why do you believe it happened?
Race
Sex or Gender
Age (40+)
Disability
Pregnancy
Religion
National Origin
Because I complained
Choose all that apply
When did it happen, or start?
(MM/DD/YYYY)
What was the frequency?
One Time
Several Times
Daily
Weekly
Monthly
Annually
When did it end or last occur?
(MM/DD/YYYY)
Was there any touching involved?
No, there was no touching
Yes, touched me inappropriately
Yes, touched me in my private areas
Did you complain to your employer?
Yes
No
No, but there is no harassment policy given to employees
Did the company have knowledge of this?
Yes, there have been prior complaints about the harasser
Yes, harassment continued after I complained
Yes, managers have seen the harasser's behavior
No, before I was harassed, the employer did not know.
Did someone say something discriminatory to you in connection with the decision?
Yes
No
Please explain what was said.
Did you complain to anyone at work?
Yes
No
Not Sure
Were you retaliated against?
Yes
No
Has this happened to others there too?
Yes
No
Not Sure
Anything Time-Sensitive
Do any of these apply?
Letter from the EEOC or a government agency
Offered a severance agreement
Asked to sign an NDA or release
I already signed something
None of these / not sure
What is the deadline date?
(MM/DD/YYYY)
In Your Own Words
Briefly in your own words, tell us what happened.
If our attorneys are unable to help, we work with a trusted network of attorneys outside the firm. Do you grant us permission to share your information with them so we can connect you with someone who may be able to assist?
Yes, please connect me.
No, please do not share my information.
I need more information to decide.
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