Preliminary Case Evaluation

Your submission will be kept in the strictest confidence and will not be shared with any third parties.

Name (Last, First)
Address (Street, City, State, ZIP)
Home Phone Number
Cell Phone Number
Email Address
Age
Race
Name of Employer
Appr. Number of Employees
Your Title
Date of Hire
Termination Date (if applicable)
Reason given for Termination (if applicable)
Date of last Discriminatory Event

Reason(s) you feel you have been discriminated against or issue(s) you feel you are going through (check all that apply)

Disability	Whistle Blowing	Gender	Sexual Harrassment
Pregnancy	Retaliation	Age	Wrongful Discharge
Equal Pay	Drug Testing / Civil Rights	Race	Medical Leave
Nationality	Wages and Hours	Religion	Infliction of Emotional Distress

What was the result of the most recent performance evaluation?
Was this result similar to prior evaluations?
Have you ever been given a verbal or written warning?
If yes, how many?
Date(s) warning(s) given (if applicable)
Are you presently on a personal improvement plan?
Do you have a written employment contract?
Is there a human resources department?
Did you raise issues or complain to a supervisor or other higher level?
If yes, what was the result?
Did you raise issues or complain to human resources?
Please give a short description of major incidents occuring within the last 180 days

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