Termination or Still Employed Evaluation ; 1 Your Contact Information 2 Employer & Work Details 3 Statuses & Legal Actions 4 Owed Wages & Details 1. Your Contact Information Your Name* First Last Your Phone* Your Email* 2. Employer & Work Details Name of Company/Employer* Address of Work Location* Job Title* Date Started Working For Company/Employer* Date Format: MM slash DD slash YYYY Date Last Worked For Company/Employer* Date Format: MM slash DD slash YYYY Date Last Paid By Company/Employer* Date Format: MM slash DD slash YYYY Number of Days worked per week* Hours Worked Per Day* How Much Do You Get Paid? Paid By: Hour Salary Other Does Company have more than 15 employees?* Yes No Does Company have more than 50 employees?* Yes No Do you work for the government?* Yes No Are you part of a union?* Yes No Do you have an Employment Contract that Guarantees employment for 1 or more years?* Yes No Do you have contact information for Human Resource department or company management? Name of Supervisor 3. Statuses & Legal Actions Complaints Have you filed a Complaint with the Company/Employer internally?* Yes No Lawsuits Have you filed a lawsuit?* Yes No Dates & Deadlines Do you have any deadlines?* Yes No Date of Deadline Date Format: MM slash DD slash YYYY Bankruptcy Have you or will you file for Bankruptcy?* Yes No Date of Bankruptcy Date Format: MM slash DD slash YYYY Unemployment Have you filed for Unemployment Benefits?* Yes No What is the Unemployment Status? Date Date Format: MM slash DD slash YYYY Disability Benefits Have you filed for disability benefits?* Yes No Disability Date Date Format: MM slash DD slash YYYY Retirement & Pension Do you have a retirement date or pension?* Yes No Retirement/Pension Date Date Format: MM slash DD slash YYYY Extended Details Are your issues related to any of the following? Pregnancy Discrimination or Harassment Sex Harassment Medical Accommodations or Medical Leave The Family and Medical Leave Act Complained about illegal activity or refused to perform illegal activity at work that can lead to government penalty, loss of licenses, etc. Age Discrimination Disability Discrimination Medical Restrictions Medical Accommodations National Origin Discrimination – Treated unfavorable - because they are from a particular country or part of the world, because of ethnicity or accent, or because they appear to be of a certain ethnic background (even if they are not). Religion Discrimination Sex or Gender Discrimination Unequal Pay due to discrimination Injury at work or because filed for worker’s compensation application or request Race or Color Discrimination Who hired you? Who terminated you if applicable and how? Who are you having issues with at work? What was the reason given for your termination or issues at work? What do you think the real reason is for your termination or issues at work? Who did you complain to at work? What exactly did you say? What was the response from the company? Did you complain about discrimination at work? What dates? Written proof? Name of Employees treated better than you and their job title: Action taken against you that was discriminatory and the date it happened? Please provide Examples and Dates - List up to 3 This iframe contains the logic required to handle Ajax powered Gravity Forms.