Free Confidential Case

Evaluation Questionnaire

If you would like a free initial review of your employment discharge or employment claim, please fully complete the following confidential questionnaire. This takes about ten minutes. After Attorney Horner reviews your responses, you will be advised as to whether your employment claim justifies further legal review. We will respond to your questionnaire within one business day.

Severance agreements are not covered by this free review of your employment claims.

If you prefer, we can send the questionnaire to you by mail.

Instructions

All responses to the following questions will be kept confidential.

Please complete ALL parts of the questionnaire that pertain to your situation.

You should complete the questionnaire as soon as possible because there may be time limitations to your claims.

You may approximate dates, ages, or amounts in your responses; we can obtain the exact information later; please use "approx" to indicate approximations.

Thank you.

1. Your Background Information

Name: *required
Address:
City, State, Zip:

Telephone Numbers
Business:
Home:
Confidential Fax:

Confidential Email:
*required
Sex:	Male Female
Race:
Date of Birth:

Social Security Number:	*optional

Education:	High School
	College Degree
	Graduate Degree

Are you currently employed? Yes No

If so, name and address of current employer:

Company:
Address:
City, State, Zip:

2. Company Information

( The following questions relate only to employment where you believe you were wrongfully treated or illegally discharged. )

I believe I may have an employment claim against:

Company:
Address:
City, State, Zip:

How many employees does the company have?

Less than 3 3 - 15 15 - 20 Over 20

Type of business:

Financial condition of company ( if known )?

Poor Fair Good Excellent

3. Employment with Company Against Whom You May Have a Claim

Initial job with this employer:

Job Title	Annual Salary	Date of Hire

Job changes:

Job Title	Annual Salary	Date Began

Most recent job with this employer:

Job Title	Annual Salary	Date Began

During the last five years of your employment did you receive any:

Salary increases?	Yes No
Bonuses?	Yes No

Give the name and job title of your current supervisor and the length of time you worked under him or her:

Name:
Job Title:
Length of Time:

Have you had problems with this supervisor? Yes No

Your job location (town and state):

Did you supervise employees? Yes No

If yes, how many?

Does the employer give written performance evaluations? Yes No

Do you have copies of your evaluations? Yes No

Was your performance generally:

Excellent Good Average Below Average

Have you ever had any performance problems prior to being discharged?

Yes No

If so, state when the problems occurred and explain:

Did you receive oral or written warnings or were you placed on probation?

Yes No

If yes, when?

When did you first become aware that your employer was dissatisfied with you?

When were you first told that you were going to be discharged?

What was said to you about why you were being discharged?

When was your last day of employment?

Have you signed a resignation letter?	Yes No
or a release of liability form?	Yes No

Do you believe the reason given for the action taken against you was false?

Yes No

If yes, explain:

Did you frequently work over 40 hours per week? Yes No

If yes, were you paid overtime? Yes No

Have you been replaced? Yes No I don't know

What percent of your duties is he/she now doing? %

Please provide the following information about your replacement (if known):

Sex:	Male Female
Race:
Age:
New Hire?	Yes No I don't know

4. Please Explain What Your Employment Claims Are

5. Employment Status with Company Against Whom You May Have a Claim

Did you have a written employment contract?

Yes No I don't know

Are you a Union member? Yes No
Did you file a grievance? Yes No

Did anyone in management give you any assurances of job security?

Yes No I don't know

Did the company have an employee handbook or personnel manual?

Yes No I don't know

6. Discrimination

Do you feel that you have been discriminated against by the company?

Yes No I don't know

Do you feel that the company treated you differently because of your:

Age	Sexual Preference	National Origin
Sex	Sex Harassment	Retaliation
Race	Pregnancy	Disability/Handicap
Religion	Vietnam Veteran

Have you ever taken a disability leave of absence or received disability payments?

Yes No

Were any discriminatory comments made?

Yes No I don't know

If yes, what were they?

Were other employees discharged at the same time as you?

Yes No I don't know

If yes, how many?

Are there any witnesses (current or former employees; customers, etc.) who could (or might) support your claims?

Yes No I don't know

7. Miscellaneous

Do you feel that you were discharged (or forced to resign) because you:

refused to perform an illegal, unethical or improper act?

Yes No I don't know

filed a Worker's Compensation claim?

Yes No I don't know

were close to receiving substantial commissions?

Yes No I don't know

had "blown the whistle" on illegal company activities?

Yes No I don't know

had opposed discriminatory acts?

Yes No I don't know

had exercised your free speech rights?

Yes No I don't know

had complained about safety violations?

Yes No I don't know

had engaged in union organizing activities?

Yes No I don't know

rebuffed sexual advances and/or were sexually harassed?

Yes No I don't know

had a personality conflict with your supervisor?

Yes No I don't know

8. Post-Employment

Were you paid all the salary, bonuses, vacation pay and commissions due to you?

Yes No

Were you informed of your COBRA rights (option to continue medical insurance)?

Yes No

Have you been disabled (or received Social Security disability payments) for any time period during the last five years?

Yes No

Have you obtained new employment? Yes No

Start Date:

If so, is the salary substantially lower? Yes No

If so, are the benefits substantially lower? Yes No

Have you filed a discrimination charge with Equal Employment Opportunities Commission or Commission on Human Rights and Opportunities?

Yes No

If your employment was covered by a collective bargaining agreement, did you file a grievance or ask your union to file a grievance on your behalf?

Yes No

Did you receive any severance pay? Yes No

If so, how much?

Around the time of your termination, were any other employees terminated?

Yes No

If so, how many?

What do you believe motivated your employer to treat you this way?

How were you referred to this office?

Speech	Yellow Pages	Newspaper Column
Internet	Other

How did you find our site?

Referred by:

Name:
Address:
City, State, Zip:

I understand that the filing deadline for claiming discrimination under Connecticut state law is 180 days from when I was first informed of the discriminatory action (i.e., when informed of discharge, lost promotion, etc.) and 300 days (from that same starting point) under Federal law. Some other deadlines may be much shorter (union grievances) and some may be much longer (torts, wrongful discharge and breach of contract).

I understand that only this discharge questionnaire will be reviewed without any expense to me and that I will then be advised as to whether my circumstances justify further review or not.

Submitting this form confirms my belief that all of my answers provided on this questionnaire are true and accurate to the best of my knowledge.

It may take some time to submit this form. Please click the submit button only once.

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