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EMPLOYMENT, CIVIL RIGHTS,
AND LITIGATION SOLUTIONS

Metropolitan Washington Employment Lawyers Association

The National Trial Lawyers Top 40 under 40

Home Questionnaire FormsFor Employee

For Employee

First Name Last Name Email Phone Number Address County City State ZIP

Best way to contact you By Phone By Email

What kind of employer or company do/did you work for? What is/was the name of your employer? Approximately how many people work for your employer? What was your date of hire? Were you hired as an employee or an independent contractor? What is/was your job title?

Are you still currently employed by this employer? Yes No

If not still currently employed, when was your last day of work for this employer?

Did/does your employer sponsor a work visa under which you were/are employed? Yes No

What state do/did you work in? What state is/was your employer based in? What is your immediate supervisor’s name? What is your immediate supervisor’s job title? Do you have any of the following:

Have you signed a severance agreement? Yes No

Have you been offered a severance agreement? Yes No

If you were paid hourly by your employer, how much were you paid per hour?

Did you work more than forty (40) hours per week for this employer? Yes No

Were you paid overtime for any hours worked over forty (40) per week? Yes No

Do you believe you were discriminated against or harassed based on: Please explain what happened in more detail: Why do you believe you were discriminated against based on the reason selected above? What discriminatory actions were taken against you, and by whom? For each discriminatory action described above, indicate the date on which the action occurred:

Were you fired? Yes No

If you were fired, what date did it happen? If you were fired, what do you think is the real reason the company fired you? If you were fired, what reason did your employer give you for the firing?

Did the employer violate its own policy in its dealings with you? Yes No

If so, is that policy in writing? Yes No

If yes, can you provide us with a copy of that policy? Yes No

Have others experienced the same problems with this employer? Yes No

Have others been treated differently than you for the same conduct? Yes No

Did you report the issue to Human Resources or your boss? Yes No

When did you make that report?

Was the report in writing? Yes No

Was there an investigation? Yes No

Did your employer take any action? Yes No

Have you found a new job? When?

Did anyone witness the discrimination you described? Yes No

If yes, please list what each witness has personally seen or experienced: What was your salary as of your most recent or final paycheck?

Is there a known deadline you are facing? Yes No

Have you ever filed a discrimination, harassment, or employment case before? Yes No

Did someone refer you to us? Yes No

Please do not include any confidential or sensitive information in this form. This form sends information by non-encrypted e-mail which is not secure.

Submitting this form does not create an attorney-client relationship.

Practice Areas

Employment Law
Civil Litigation
- Alternative Dispute Resolution
- Civil Litigation and Appeals
Civil Rights

1550 Wilson Blvd #700

Arlington, VA 22209

Phone: (703) 791-9087

We serve the following localities: Alexandria; Arlington; Fairfax; Falls Church; Fairfax County including Annandale, Burke, Centreville, Chantilly, Clifton, Great Falls, Herndon, Lorton, McLean, Mount Vernon, Newington, Springfield, West Falls Church, West Springfield, and Vienna; Loudoun County including Leesburg and Sterling; and Prince William County including Dale City and Manassas.

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For Employee | Northern Virginia Employment Lawyers The Erlich Law Office

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