AGE and RACE DISCRIMINATION,  SEXUAL HARASSMENT  


Discrimination in employment is difficult to prove. Most acts of discrimination are not obvious. An attorney must look at all aspects of the employment relationship to determine if a client has a viable complaint against the employer. The questionaire on this page is intended to reveal if you have a valid complaint. For a no-charge review of your case, fill it out and mail to my office (Click).


NAME:____________________________

ADDRESS:_________________________

TELEPHONE:_______________________

SOC. SECURITY NO.:________________




CHECKLIST  FOR INVOLUNTARY TERMINATIONS
(Includes Layoff, Discharge, Forced Resignation/Retirement)

EMPLOYMENT PROFILE

Company Name:___________________
Subsidiary of:__________________
Job Title:______________________
Location:_______________________

Number of Employees in Company ______At this location ____
When did you receive notice of termination? _________
Company's reason for termination? ________

Do you agree with the Company's reason for termination?____ If not, why not? __________

Are you eligible for rehire/recall? ______

When was/is the last day yon will be/were actually present on the job?_______

First date of Hire?________

Any breaks in service?_____

Reason for service break?______

Earnings?__________ per hour, week, month? (Circle)

Date of Birth _________

Physical handicaps, disability or work restrictions?____
Describe:_________________________

Race______Sex________________ Citizen of U.S.?

How many other employees were terminated when you were?_____

How did you find out about the job you were hired for?_____

Who made the first contact? Company _____ Recruiter Employee

If you were employed at the time you were hired by the company, by whom and for how long?

Were promises of job security made when hired?____ If so, by whom? In writing?_____ When?____

Did you relocate to work for the company?

Did the company pay for relocation?

How are you paid: Salaried? Exempt?
Commission?
Hourly?
Non—exempt?
Bonus?________

II.SEVERANCE PAYMENTS

Did you receive severance pay?______

According to company policy? _________

Amount Paid?_______

Did you sign a release to receive severance pay?

How much time were you given to review the Release and discuss it with others before signing?

Did you receive any vacation pay; disability pay, early retirement incentive pay, unused sick pay, pension, pension supplement, vested health/life insurance, deferred pay? (Circle)

Will  you forfeit any bonus or incentive pay because of termination?

Has your Total of pension or savings plan vested?
List all payments made upon termination.
Lump sums $_____________

Continuing _______/month


III. EMPLOMENT POLICY

Has your company given you an employee's handbook? _____

Are you covered by a union contract? _____

Do you have a copy? ___________

Does your company have an internal complaint or grievance procedure? ___________

Did you request it? ______ When? _________________ outcome?

Do you have bumping rights?_____

Who is now or will be doing your work? ___________________________

Were you replaced by another employee or a new hire? _____________

What is the age _____ sex _____ race_____ and date of hire __________________ of the replacement?

Were you offered another position instead of layoff?

Would the offered job require relocation?_____

Were you offered outplacement?_____


Do you know if any employee transfers took place before your layoff?_____

Did you receive a COBRA letter from the company?____


PERSONNEL FILE


Describe your disciplinary record, if any. Give incident date, reason for discipline and discipline received:





Did you ever grieve or appeal any disciplinary step?_____ What was the result of any grievance or appeal?
Were you ever placed on probation?_____  When?_______Were you warned that you would be terminated?_____How long before?______ Was warning written?_______Were you suspended prior to discharge?______ Did the termination come as a surprise to you?______Does the company give performance evaluations?_______ How often?_______per year.When were you last evaluated?_______
Were you warned that your behavior could result in discharge at the last performance review?_______

Were others like you evaluated?

What was the amount and date received of your last two (2) wage increases for this employer?


PROTECTED ACTIVITY


Have you ever filed for worker's compensation?____
When?
Describe:

Have you ever notified the company that you have a serious disease?

Have you ever refused to work under, or complained about, unsafe working conditions or worked around hazardous substances?____
When?

Have you ever filed or threatened to file a lawsuit, Civil Rights complaint, OSHA complaint, Wage/flour complaint or NLRB charge against the company?__________ When? ___________ Describe: _____


Have you every complained of sexual harassment? If so, be specific and state the worst instance of sexual harassment in your memory. Remember harassment is a conclusion made after the facts are known. Your factual recollection should reveal what exactly  happened? who did it? when did it happen? physical contact? any threats made if you did not submit? Do not mistake crude or poor management styles for sexual harassment - your mistreatment must be because of your sex.

Describe:



Have you ever requested company assistance for treatment of substance abuse? (drugs, alcohol) ________   When? _____

Have you ever complained to the company about improper withholding of tips, customer fraud, unfair trade practices, questionable accounting methods, kickbacks to suppliers or customers, government contracting violations, illegal gifts or donations, timekeeping methods, safety hazards
or product safety? _________________


When? ___________________________________________________
Describe:

Have your wages ever been garnished?______ When?____

Have you:

Served jury duty in the past year?
Taken personal leave in the past two years?___
Reason for leave____________
Was leave fully paid?_____; partially paid?____

Ever refused a physical examination? ______ Drug test? ______
Been incarcerated while employed by the company? ______
Asked for religious accommodation (e.g. time off)? _____
Distributed union literature? ______
Violated a company no solicitation rule? _____
Taken unauthorized voting time? ______
Complained of employee misconduct in your work area?
Been asked to take a lie detector test?

Fill out and return. You will get a response!