Questionnaire

The following information is necessary for an initial evaluation of an employment claim. If you are coming in to discuss an employment matter, we ask that you first prepare by answering the questions below. You may wish to submit this electronically and print out the filled-in version for your records.  Or you can print this out and fill it out by hand to bring with you to your first appointment with us.

Personal Information

Name: 

Address:

Work Number:

Home Number:

What is your age?

What is your race? (If relevant to your complaint.)


Employer Information

What is the name of the Employer?

Employer address:

Employer telephone number:

Name of Employer's representative:

What is the name and title of the Employer representative who advised you of the action you are complaining about?


Who was your supervisor at the time?

What was your job title?

What was your rate of pay?

How many hours a week did you normally work?

Were you paid overtime pay for any time above forty (40) hours worked in a week? 

When were you hired?


Employment Information

Did you have an employment contract? (If so, please provide a copy and keep the original for your files.) 

Were you covered by a union contract? (If so, please provide a copy.)  

Did the Employer have an employee handbook or similar manual? (If so, please provide a copy.)

Were you given performance evaluations by the Employer? Were they oral or written or both? (If written, please provide a copy and keep the original for your files.)

Were you ever given a raise based on your performance?

Have you ever been promoted? When?

Have you ever been disciplined prior to the action you are complaining about? If so, please describe when, why, and how:


Have you obtained a new job since the action you are complaining about? If so, what is the name of the new Employer?


Job title and rate of pay of new job:

Were any benefits lost compared to what you received in the old job? If so, describe:


Case Information

Briefly, what happened to you?







Briefly, why do you believe what happened to you was wrong?







On what date did you first learn of the action you are complaining about?

Was the notification written, oral, or both? (If written, please provide a copy and keep the original for your files.)

Did the Employer give any reason or reasons for the action, and what was the reason(s) given?







What do you believe is the real reason for the action?







Do you have any witnesses with first-hand information regarding the action you are complaining about?

Please provide each witness’ full name and an address and phone number:







Describe what each witness can say that relates to your case:







Have you ever filed a charge of discrimination? If so, please provide a copy, and keep the original for your files.)

Have you ever filed a grievance? (If so, please provide a copy and keep the original for your files.)

Have you ever filed a worker’s compensation claim? (If so, please provide a copy and keep the original for your files.)

Have you filed an unemployment compensation claim since the action you are complaining about? Was there a written decision on your claim? (If so, please provide a copy and keep the original for your files.)

Have you sought any medical or psychological treatment or counseling since the action you are complaining about?

If so, beginning when?

Name of treating professional:

Had you ever been treated for this reason before the action you are complaining about?

If so, when?

Reason that treatment was needed:







What do you want from the Employer because of the action you are complaining about?







Protecting & Expanding Employee Rights

David R. Levinson, Attorney at Law
P.O. Box 39286
Washington, DC 20016
Phone: (202) 223-3434
Fax: (202) 659-1034
Email: levlaw@gmail.com

The information you obtain at this site is not, nor is it intended to be, legal advice. You should consult an attorney for individual advice regarding your own situation.

Copyright © 2011 by David R. Levinson. All rights reserved.