Were you ever known by a different name? Yes No
If so, what?
Do you speak English with ease? Yes No
If not, what is your preferred language?
Name of Employer
How many employees work for the company?
1 - 4 5 - 15 16 - 50 51 - 100 Over 100
Were you an employee or an independent contractor?
Employee Independent Contractor
When were you hired?
Most recent salary or hourly wage
Are/were you a union member?
If yes, what is the name of the union?
TELL US WHAT HAPPENED:
Do you believe that you have been harassed, discriminated against or retaliated against at work due to your race,
religion, national origin, age, physical or mental disability, medical condition, gender, sex, or sexual orientation or
for complaining about discrimination or harassment? Yes No
Do you believe that you were retaliated against for objecting to illegal conduct at work? Yes No
I complained to my employer regarding...
Failure to pay wages and/or overtime Safety issues Harassment Discrimination Failure to follow the law
What type of harm have you suffered? (select all that apply): Termination Demotion Denial of Promotion Denial of Equal Pay Cut in Hours Harassment Retaliation Denial of Accommodations Transferred to Worse Position FMLA/CFRA Other
Choose the reason(s) for the harmful action(s) taken against you: Race Age Gender/Sex National Origin Sexual Orientation Pregnancy Physical Disability Mental Disability Medical Condition Request for FMLA or CFRA Religion Marital Status Ethnicity Gender Identity Military Status Whistleblowing Other:
Please provide a summary of the reasons why you believe you were treated wrongfully by your employer.
On what dates did this/these event(s) happen?
Did you ever complain to your employer about the harmful actions against you (either orally or in writing)? Yes No
If yes, on what date(s) and to whom did you complain?
Are you still employed with this employer?
If not, were you fired or did you resign?
If applicable, when did your employment end?
What reason(s) did the employer give for your termination?
What is the true reason for your termination?
If you sued by your employer, what do you think they would
say in their defense of firing you?
Identify each person who has engaged in an act of harassment, discrimination
or retaliation against you stating their name(s) and job title(s):
Are you disabled?
If so, what is/are your disability(ies)?
Have you ever requested an accommodation of a disability from this employer?
If so, what accommodation?
Did you ever complain to your employer regarding their wrongful conduct?
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:
Are there other facts suggesting discrimination or unfair treatment such as discriminatory remarks,
under-representation or other employees being treated better? If so, please explain:
Do you know who replaced you? Yes No
If so, who?
Have you ever taken a leave of absence from work?
If so, when (dates) and for what reasons?
Do you believe you were fired or harmed in another way for taking a leave of absence?
Were you paid overtime for working more than 40 hours per week or 8 hours per day?
If not, please explain your duties:
Were you given a 30 minute off-duty meal break for each 5 hours that you worked:
Were you reimbursed for work-related expenses such as cell phone, uniforms,
mileage (other than commuting), travel, supplies, etc.?
Did you have a written contract for employment? Yes No
Did the Company have written personnel policies/Employee Handbook? Yes No
Was your employment at-will, or were you promised you would not be terminated without good cause? ---At-WillGood Cause
Did anyone at the company promise you job security? Yes No
If so, what was said?
Did the company use progressive discipline? Yes No
Did the company use a grievance procedure? Yes No
Did you receive written performance evaluations? Yes No
What do they say?
Did you receive verbal performance evaluations? Yes No
What was said?
Have you ever been involuntarily terminated from a previous employer? Yes No
If yes, please explain:
Have you spoken to, met with, or corresponded with any other attorneys regarding this issue?
Have you ever sued anyone before or been sued before?
If so, please explain:
Have you ever filed a workers' compensation claim? Yes No
If so, when?
Have you ever filed for bankruptcy?
Have you been convicted of a crime in the past 10 years?
If so, what?:
Have you filed a complaint with the Department of Fair Employment and Housing (DFEH)
or the Equal Employment Opportunity Commission (EEOC)?
If yes, have you received a Right-to-Sue letter?
Have you filed a complaint with the Department of Labor Standards Enforcement ("DLSE"/Labor Commissioner)?
Did your employer have you sign an arbitration agreement, either as part of a handbook or given to you as a separate document?
Please list all social media accounts and blogs (if any):
How did you hear about us?
If there is any other information that you wish to provide us to assess your situation, please provide it here:
PLEASE READ CAREFULLY BEFORE SUBMITTING
Although the information you provide to us on this form is confidential, completion and/or submission of this form to us
does not create an attorney-client relationship between Hekmat Law Group (the "Firm") and you. No attorney-client relationship
shall exist until you and the Firm make a mutual decision to work together and make a written agreement stating the specific
terms of that attorney-client relationship. While this questionnaire does not create an attorney client relationship, your information
will be confidential and privileged. We will not disclose your information and you may not be compelled to disclose your
communications with us to anyone.
Please note, if you have time deadlines (or statutes of limitations) that are quickly approaching, we cannot guarantee that we will
respond in time for us to assist you in filing a lawsuit or administrative agency complaint. You should take immediate action to avoid
missing any such deadlines. The time within which a charge for discrimination must be filed with the United States Equal Employment Opportunity Commission is 300 days from the claimed unlawful act. The time limit to file a charge of discrimination with the California
Department of Fair Employment and Housing is 365 days from the claim unlawful act. Generally, the time to file other employment
related claims in court is one year from the date of harm, e.g. termination, demotion or transfer.
By submitting your matter below, you acknowledge that you have read and understood the foregoing.