Name *

First Name

Last Name

Call Back Number *

(###)

###

####

Good Time to Call Back

Hour

Minute

Second

AM PM

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Employer's Phone

(###)

###

####

Employer's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Began Employment

Tell me when the problem started (e.g. date of hire, contract execution, first important occurrent).

MM

DD

YYYY

Ended Employment

Tell me when the last importance occurrence happened (e.g. employment ended, last incidence of harassment, date contract was breached).

MM

DD

YYYY

Still Employed?

If you're an employee, are you still employed?

Yes

No

Supervisor's Name

Provide the name of the person who is most at fault (you can describe additional persons at the end).

First Name

Last Name

Workplace Problems

Check all that apply

Sex or gender Discrimination

Sexual orientation Discrimination.

Transgender status Discrimination.

Race or National Origin Discrimination.

Disability or Medical Condition Discrimination.

Workers' Compensation use Discrimination.

I Refused to Engage in Illegal Actions.

I Reported Illegal Actions.

Coworkers or my supervisor make make fun of, tease, or harass me.

I am being subjected to a hostile work environment.

Someone is publishing bad stories about me to others (including potential employers).

Someone is publishing bad stories about me on the Internet (Facebook, LinkedIn, etc.).

I asked for a leave of absence for medical or other reasons but was denied (FMLA, CFRA).

My leave of absence was cut short (because I was terminated or bullied into coming back to work prematurely).

I was denied intermittent leave of absence.

I am not being paid overtime.

I am not being paid minimum wage.

I am an Independent Contractor, but I have no control over my schedule.

I am "Exempt from Overtime," but I am not in management.