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Your Name:

Phone (Day/Evening and/or Work, Home, or Cell):

Email Address:

NOTE: Please do not use an email provided by your employer

Home Address

Name of Employer:

Location of Workplace and Employer:

Do you have a union?

Yes

No

Brief Summary of Your Case:

Approximate Number of Employees:

Your Position:

Briefly describe your typical duties:

Are you paid a salary or an hourly rate?

Salary

Hourly

Salary or Hourly Rate:

Length of Employment:

If you quit or were terminated, date of resignation or termination

Did/Do you have an Employment Contract?

Yes

No

I don't know

If you are not now employed, under what circumstances did you leave?

If you were terminated or laid off, what was the reason your employer gave you (even if you did not believe it)?

If you do not believe your employer's reason, what do you think the real reason was?

Other than or in addition to your termination, is there another reason leading you to contact an attorney?

If your complaint is about sexual harassment, describe the nature of the harassment:

What is the harasser's position? (i.e., supervisor, co-worker)

What do you think is causing/caused the sexual harassment?

Did you complain about the sexual harassment?

Yes

No

If yes, to whom did you complain and what was done about it?

If your complaint is about discrimination, what type of discrimination? (check all that apply):

Gender

Race

National Origin

Ancestry

Mental Disability

Physical Disability

Age

Sexual Orientation

Marital Status

Medical Leave

Retaliation for Opposition to Discrimination

Retaliation for Whistleblowing

Other

If age discrimination, how old are you?

If your complaint is about sexual harassment or discrimination, have you filed a claim with the EEOC or Ohio Civil Rights Commission?

Yes

No

If your complaint is about unpaid wages, what kind of wages do you believe are due?

Did/Does your employer keep track of your hours worked? (i.e., time clock, time cards)

Yes

No

If salaried, do you believe you are/were properly classified as an exempt employee? If not, why?

Were/Are you classified as an independent contractor?

Yes

No

If yes, do you believe you should be/should have been classified as an employee? If so, why?

Did/Do you normally work over 40 hours per week?

Yes

No

If yes, how many hours per week did/do you work on average?

Did/do you get paid time and one-half for your overtime (hours over 40 in a week)?

Yes

No

Are there other current or former employees that are in the same situation?

Yes

No

Any additional comments?

Law Office of Nancy Grim

Northeast Ohio Employment Attorney

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