Trucking Accidents lawyers Durham

Employment Case Information

Please fill out this form as completely as possible. In order to evaluate your case, we must have complete responses to the questions. All information your provide is confidential. After we have received your completed form, an attorney will review your case and determine whether or not this firm can represent you. We will contact you within one week of receiving your completed form to inform you of our decision or to request additional information. You can also download and fill out a paper form. Please return your completed form immediately, as there may be important deadlines in your case. THIS FIRM DOES NOT REPRESENT YOU AT THIS TIME. If you need immediate legal assistance, you should contact another attorney.

Your Name (required)

Date of Birth

Your Email (required)

Address

City

State

Zip

Home Phone

Work Phone

Employer

Employer's Address

Your Job Title

Your Supervisor

Annual Salary/Hourly Wage

Number of Employees

Have you been

When Did This Happen?

Briefly describe what happened

What reason, if any, did your employer give for taking this action?

What do you think was the true reason your employer took this action?

Do you believe you have been discriminated against for any of the following reasons?
 Race Sex Age Disability Pregnancy Filing Worker's Compensation Claim Injured on the job 'Blowing the whistle' on improper activity None of the Above Other

Please explain your above answer

Have you filed a Charge of Discrimination with the EEOC or any other agency?
 Yes No

Have you received a "Right to Sue" from the EEOC or any other agency?
 Yes No

If so, what is the date on your Right To Sue letter?

What specifically makes you think you were discriminated against?

Did anyone in the workplace make comments about race/ sex/ age/ disability/ etc?
 Yes No

If so, who?

What were the comments?: (please use exact quotes if possible)

How long have you been employed with this employer?

Have you had any evaluations?

Were they generally good or bad?

Have you received any complaints or warnings about your work? If so, please describe

Are you still working for this employer?
 Yes No

If no, have you found another job?
 Yes No

How much does it pay?

Additional Questions For Harassment Cases
If you have been harassed, please answer the following questions:

Name of Harasser?

Harasser Job Title?

Relationship To You?

Briefly describe exactly what the person said or did to harass you: (use exact quotes if possible)

Did you complain to anyone about the harassment?
 Yes No

To Whom?

When?

What was their response?

Was any action taken against the harasser?

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How did you hear about our firm?

Do you have another attorney representing you at the present time?
 Yes No

If so, who?

What would you like an attorney to do for you?

The completion of this form for communication with the firm does not establish an attorney-client relationship.