Civil Intake Questionnaire

Date(Required)

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Email(Required)

Phone(Required)

Pronouns(Required)

Date of Birth(Required)

Name of Employer(Required)

Name of Entity Issuing Paycheck(Required)

Dates of Employment(Required)

Job Title and Brief Description of Duties(Required)

Number of Employees within 75 miles

Earnings(Required)

Still Employed?(Required)

Last Day(Required)

Paid Severance(Required)

Date of most recent act of discrimination/retaliation/harassment:(Required)

Please describe the act(s) of discrimination/retaliation/harassment, including the persons involved:(Required)

Why do you think you are being targeted (race/national origin, mental/physical disability, age, sex/gender, pregnancy, religion, need for reasonable accommodation, etc.)?:(Required)

If disability, have you received either workers’ compensation benefits or State Disability Insurance (SDI) for the disability for which you are being discriminated against?(Required)

When did your WC/SDI benefits begin?(Required)

Have you filed a charge of discrimination with the California Department of Fair Employment and Housing (DFEH) or the United States Equal Employment Opportunity Commission (EEOC):(Required)

Start date of DFEH/EEOC claim:(Required)

Type of discrimination claim you made (race, age, gender, etc.):(Required)

Do you have a social media presence (such as Facebook, Twitter, Instagram, Bumble, Tinder, OKCupid, Hinge, LinkedIn, WhatsApp, Pinterest, etc.)?(Required)

Please list the platforms on which you have a social media presence:(Required)

Did you make social media posts about the facts that give rise to your potential claims against the employer?(Required)

Where did you go to High School?(Required)

Other education or training (AA or BA)?(Required)

Alternative Contact:(Required)

Previous Lawsuits:

Upload any relevant documents:

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Accepted file types: jpg, gif, png, pdf, Max. file size: 512 MB, Max. files: 5.

Civil Intake Questionnaire

Formulario De Admisión Civil

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