Potential Client Questionnaire

How did you hear of us? *

Name *

First

Last

Email Address *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Cell Phone *

Alternative Phone

Age

Gender

Male
Female

Name of Employer(s) *

In what city did your employment occur?

How many employees work for the company / employer *

Were you an employee or an independent contractor?

Employee
Independent Contractor

When were you hired?

Job Title

What were your job duties?

Most recent salary or hourly wage *

Are / were you a union member? *

Yes
No

If yes what is the name of the Union *

Are you still employed with this employer? *

Yes
No

If not, were you fired or did you resign? *

If applicable, when did your employment end? *

What reason(s) did the employer give for firing you?

What is the true reason(s) why your employer decided to fire you?

Did you have any poor performance reviews?

If you sued your employer, what do you think they would say in their defense of firing you?

Do you believe that you have been harassed, discriminated against or retaliated against at work for any reason (for example, race, religion, national origin, age, physical or mental disability, medical condition, gender, sex, sexual orientation, or for objecting to illegal conduct—including complaining about discrimination or harassment based on a protected category?) If so, list all facts supporting your claim

Has it been more than one year since the above events took place? *

Yes
No

Identify each person who has engaged in an act of harassment, discrimination or retaliation against you, by stating their name(s) and their job title(s):

Have you spoken to, met with, or corresponded with any other attorneys regarding the issue you wish to speak with us about?

Yes
No

If so, to whom? What did you say and when? (name and job title):

Are you disabled? *

Yes
No

If so, what is/are your disability(ies)?

Have you ever requested an accommodation of a disability from this employer? *

Yes
No

If so, what accommodation?

Did you ever complain to your employer regarding their wrongful conduct? *

Yes
No

If so, to whom, when and what did you say? (name and job title):

Do you have any witnesses or documents to help you prove your claims? *

Yes
No

If yes, describe and include witness contact information, their position at the company, and whether or not they are currently part of your employer’s management:

Have you ever taken a leave of absence from work? *

Yes
No

If so, when (dates) and for what reasons?

Do you believe you were fired for taking a leave of absence? *

Yes
No

Are/were you paid overtime for working more than 40 hours per week or 8 hours per day? *

Yes
No

If not, please explain your duties:

Are/were you given a 30 minute off-duty meal break for each 5 hours that you worked: *

Yes
No

Were you aware of any potential performance issues (whether verbal, PIP, written warning, or otherwise)?

Were you reimbursed for work-related expenses (cell phone, uniforms, mileage (other than commuting), travel, supplies, etc.)? *

Yes
No

Have you ever sued anyone before or been sued? *

Yes
No

If so please explain:

Have you ever filed or are you thinking of filing for bankruptcy? *

Yes
No

If so, please explain:

Have you been convicted of a crime in the past 10 years? *

Yes
No

If so, what?

Have you ever filed a workers' compensation claim? *

Yes
No

If so, when (dates)?

Do you believe you were fired for filing a workers' compensation claim?

Yes
No

What was your date of termination?

Were you incarcerated at anytime during your employment with this employer?

Have you found another job since losing the job in question? *

Yes
No

If so, when did you start and how much do your earn at this new job?

COMPLAINTS TO GOVERNMENTAL AGENCIES Section

Have you filed a complaint with the Department of Fair Employment and Housing (DFEH) or the Equal Employment Opportunity Commission (EEOC)? *

Yes
No

If yes, have you received a Right-to-Sue letter?

Yes
No

Have you filed a complaint with the Department of Labor Standards Enforcement ("DLSE"/the Labor Commissioner)? *

Yes
No

If yes, what is the status

Did your employer have you sign an arbitration agreement, either as part of a handbook or given to you as a separate document? *

Yes
No

Potential Client Questionnaire

COMPLAINTS TO GOVERNMENTAL AGENCIES Section

Shirazi Law Firm, PC