Kevin Chaffin Law Offices in Ventura
   
 

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Wrongful Death
Wrongful Termination
Sexual Harassment
Hostile Work Environment
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Retaliation and Whistleblower
Discrimination
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Discrimination Questionare

PLEASE NOTE:
This questionnaire is meant solely for the use of the consulting attorney for purposes of analyzing and evaluating the prospective client's case. The contents of this document are therefore protected by the attorney-client privilege and the attorney work product doctrine. It is very important that you be completely truthful, accurate and complete in answering the following questions. The defendant in this case will likely obtain all relevant records about you. Therefore, it is crucial that we are aware of all information, including information you may believe will damage your case, in order to best represent you. If we decline to take your case, it does not mean you do not have a case. Therefore, if we decline your case you should contact another attorney. Most of our clients are employees or injured persons. If you are an employer, or you are concerned you might be sued by someone else, do not complete a questionnaire. Instead, you must first contact our office by telephone.

GENERAL BACKGROUND INFORMATION
1 What is your name?

2 What is your age?

3 What is your mobile cell phone number?

4 What is your home phone number?

5 What is your e-mail address?

6 What is your street address?

City

State

Zip Code

7 What is your Social Security Number?

8 What is your California Drivers License Number?

9 What is your Date of Birth?

CURRENT EMPLOYMENT INFORMATION
10 What is the name of your current employer? (If unemployed, write none)
11 What is your current employer's address?


12 What is your current job title?

13 What is your current rate of pay?

14 What is your supervisor's name?

15 When did your current employment begin?

16 How many employees work for your current employer?

EMPLOYMENT CLAIM INFORMATION
17 What type of employment claim do you believe you have?
(Check all that apply)
Wrongful Termination Constructive Discharge (Forced to Resign) Wrongful Demotion Wrongful Failure to Promote Sexual Harassment Hostile Work Environment Discrimination [Race, Age, Religion, Sexual Orientation, Pregnancy, National Origin, Physical Disability, Mental Disability, Request for Medical Leave] Retaliation or Whistle blowing [select this if you feel that you were terminated, harassed, or demoted in part because you refused to violate the law, protested violations of law, protested unsafe work conditions, complained about non-payment of wages or overtime, complained about discrimination or harassment of yourself or another employee, testified against an employer, cooperated in an investigation against an employer, or engaged in other such protected conduct.] Failure to Pay Wages / Commissions / Bonuses / Overtime / Provide Breaks
18 What is the name of the Employer against whom you believe you have a claim
(The name of the company or individual that terminated you, discriminated against you, harassed you, retaliated against you, failed to pay you wages, retaliated against you, etc.)

19 What date were you hired by the Employer?

20 Your title when you were hired by the Employer?

21 Your rate of pay when you were hired by the Employer?

22 What is your current title or your title at the time you were terminated/demoted/etc?

23 What is your current rate of pay or your rate of pay when you were terminated/etc?

24 What is the name and position of your most recent supervisor?

25 Do you have a written employment contract?

26 Have you ever been told that you can only be fired for "good cause?"

Explain in detail what you were told and identify the person with whom you had the discussion:

27 Does the company have an employee handbook or manual that provides for progressive discipline?

28 Does the employee handbook or manual state that your employment is "at will" and that you may be fired for any reason?

29 Have you signed a form stating that you agree to submit all disputes related to your employment to arbitration?

30 Are you a member of a Union?

31 Have you filed a grievance with your union regarding this problem?

32 If terminated, state what the Company said its reasons were for terminating you.
(If you were told it was a layoff, state the reason the company gave for selecting you for layoff instead of other employees that hold the same or similar positions):

33 If terminated, please explain what you believe was the actual reason that the company terminated you.
(If you believe the company truly reduced its workforce, and eliminated one or more positions, please explain why you think they chose you for layoff instead of other employees that hold the same or similar positions. In other words, we want to know what you think the motive was, not what the company told you its reasons were.)

34 If you were laid off, pursuant to a reduction in force, please list each employee that held a position similar to yours that was retained by the company when you were laid off. If your claim is discrimination based on age, race, gender, national origin, etc - , please also state the age, race, gender, or national origin of the employees that were retained. For each such employee, please also explain why you think that employee should have been laid off instead of you. For example, if you were laid off over an employee that had less seniority, less experience, less education or training, state that next to that employee's name (BE SPECIFIC).

35 If your employer told you that it fired you for violating some company policy, or disciplinary rule, or regulation (e.g., absenteeism, tardiness, theft, timecard fraud, unsafe workplace conduct etc - ), please list each and every other employee that you believe engaged in conduct of the same severity and frequency, but was not fired. If your claim is discrimination based on age, race, gender, national origin, etc - , please also state the age, race, gender, or national origin of the employees that were retained. If your claim is based on whistleblowing, please state whether the employees that were not disciplined as severely as you also engaged in whistleblowing. Also state what misconduct each of the listed employees actually engaged in, when, how frequently, and the name of any supervisors that knew the employee committed the misconduct that you contend was as severe as that for which you were fired.

36 Please list any supervisors or managers to whom you complained about discrimination, harassment or whistleblowing, including the dates of all such complaints. Be sure to state whether the complaints were oral or written and, if written, whether you have a copy.

37 Did your employer follow company policy and procedure in handling your dispute?

38 Do you feel you were treated differently from other employees in similar circumstances?

If "yes", please explain

39 Do you feel race, age, sex, national origin, religion, sexual orientation, medical condition, taking medical leave of absence, pregnancy, or disability (physical or mental) was the cause of this difference in treatment?

If so, why?

40 If you believe that any of the above-listed characteristics might have motivated the employment action taken, please describe in detail, each and every fact upon which you base that conclusion. Possible evidence may include the following:
(a) Statements or remarks by management: Examples of possible evidence of racial motive include, racial comments, stereotypes, jokes or comments by management, or comments by co-workers, of which management knew about. Also comments that you are not a "team player" might indicate a retaliatory motive.
(b) Others were treated more favorably in similar situations: If other employees who did not have your protected characteristic (were not of the same race, age, gender, or were not disabled), were in treated better in similar situations, that may show discriminatory motive. For example, if you are a woman and were fired for being late, the fact that other male employees were also late but were not fired, would constitute evidence of discrimination.
(c) Statistics: How many total employees at your company vs. how many employees of your gender, race, age or national origin. For example, if your company has only 2% Black employees, but 25% of the applicants are Black, that would tend to prove racism. Also, if Blacks, or women, or older workers make up only 10% of the workers at your company, but 50% of the terminations or suspensions, that would tend to support an inference that the terminations or suspension decisions were motivated by some protected characteristic.
41 List the name address and telephone number, if available, of any witnesses to incidents described above:

42 List the names of any other employees (current or former) who you believe have been treated like you?

43 Describe any documents that you believe support your case?

44 Was your work performance evaluated in writing? If so, please state the date of each evaluation and the overall rating you received. If please indicate whether you have copies of each evaluation.

45 Have you received any commendations, letters or memos telling you that you were doing a good Job?

46 Have your ever been disciplined, counseled, or warned about deficiencies in your work performance or violations of company policy at any time during your employment? If so, please state the date of each incident, the discipline imposed, the conduct for which you were disciplined and state whether you told your employer that you agreed or disagreed with the disciplinary action taken. Please provide all documents related to these incidents, including the write-up and memos, if they exist.

47 Have you ever been terminated or asked to resign from employment before?

If so, please describe, including the reasons given for your termination?

48 Did you inform anyone in management of your complaint?

If so, state the date, name and title, of the person you informed and what actions were taken, if any, to resolve your complaint.

49 Does your company have an internal complaint procedure?

If so, did you file a complaint?

When? What was the result?

50 Have you filed a Union grievance?

What happened?

51 Have you filed a charge with the U.S. Equal Employment Opportunity Commission (EEOC)?

When? What happened?

52 Have you filed a charge of discrimination, harassment or retaliation with the California Department of Fair Employment and Housing?

When? What happened?

53 Do you have a copy of any charge filed with the EEOC or the Department of Fair Employment and Housing?

If so, please attach copies.

54 Have you received a "Right to Sue" letter?

When?

55 If terminated, have you applied for unemployment benefits?

When? Result?

56 Did anyone appeal the initial decision of the unemployment office?

If so, who appealed?

57 Have you examined your personnel file?

If so, briefly state any fact of importance contained in or missing from your personnel file:

58 Describe the effect of your discharge or other action taken against you by your employer on your income; medical or pension benefits; profit sharing; or other financial impact:

59 Describe the effects of your discharge or other action taken against you by your employer on your health and/or personal life, family relations, and opportunities for other employment?

60 60 Have you sought any medical treatment or counseling because of your employment problems?

If so, describe:
Identify which of the emotional problems you now have that you had before the incident that caused you to seek legal counsel. In other words, which problems did you have before the harassment or discrimination even took place. Be sure to think carefully about this question because the defendant will subpoena all records from doctors, therapists or psychiatrists to determine whether you already had any or all problems you claim were caused by the defendant.

CURRENT EMPLOYMENT INFORMATION
61 Have you ever filed a lawsuit before or have you ever been sued before?

If so, please explain:

62 Have you ever filed for bankruptcy before, or are you considering filing bankruptcy in the near future?

If so, please state the date you filed and the result, (or state the date you are planning on filing bankruptcy. (****Note if you are planning on filing bankruptcy anytime soon do not sign or file any bankruptcy documents without consulting with this office first, as filing a bankruptcy action could result in the termination of your lawsuit****)

63 Have you ever been arrested?

If so, please state the date, the charge/s and whether you were convicted.

64 Have you ever filed a workers compensation claim for any injuries sustained at work?

If so, state the date of complaint and the result?

 
Chaffin Law Office - P.O. Box 3076, Ventura, California 93006 - Phone 805-650-8200 - email: info@chaffinlaw.com