Caskey & Holzman, Attorneys at Law

Caskey & Holzman
6255 Sunset Blvd
Suite 2212
Los Angeles, CA
90028
(323) 467-2100 (ph)
(323) 461-1823 (fx)
EMPLOYMENT / HARASSMENT CASE QUESTIONNAIRE


1. Name:
Contact: (Phone or Email)
Additional Contact: (optional)
 
2. Employer: (General description will suffice)
 
3. # of Employees: (Approximate number will suffice)
 
4. Length of Employment:
 
5. Position:
 
6. Salary:
 
7. Do you contend you were wrongfully terminated?

If so, provide the following information:
A.   Date of termination:
B.   Position of person who terminated you:
C.   What reason were you given, if any:
D.   If you disagree with the reason given, what do you believe was the cause of your termination?
E.   Are you re-employed yet?
 
8. Do you contend you have been harassed or discriminated against?

If so, provide the following information:
A.   Position of person who has harassed or discriminated against you:
B.   Does this person harass or discriminate against you because of your age, sex (including sexual harassment), pregnancy, race, religion, national origin, disability, sexual orientation? If so, which one:
C.   If this person does not harass or discriminate against you because of one of the categories listed above, please provide a brief statement as to why you believe this person harasses or discriminates against you:
D.   Have you reported the harassment or discrimination to any supervisor or manager?

If so, provide the following information:
(1)   Position of person receiving the complaint:
(2)   Date the complaint was lodged:
(3)   Was the complaint verbal or in writing:
(4)   Provide a brief description of your employer's response to your complaint:
(5)   Did the harassment or discrimination continue after your complaint?
yes no
E.   Have you received a right to sue letter from either the DFEH or the EEOC?
yes no
If yes, when:
 
9. Do you contend you are owed wages, commissions, or tips by your employer? If so, provide a brief description of why you believe this money is owed and the amount of money you contend is owed:
 
10. Do you contend you were improperly denied a medical leave? If so, provide a brief description of why you believe the denial was improper:
 
11. If your situation is not covered above, provide a brief description of facts relevant to your claim:

 
 
SEND