The Law Office of Edward A. Torres - Client Questionnaire

C O N F I D E N T I A L Q U E S T I O N N A I R E This is our new client questionnaire designed to determine the merits of your case. We will review your questionnaire and contact you via email with what you can expect, next steps and suggestions. This questionnaire is meant solely for the use of the consulting attorney for purposes of analyzing and evaluating the prospective client’s case. The contents of this document are therefore protected by the attorney-client privilege and the attorney work-product doctrine. If we decline to take your case, it does not mean you do not have one. You should contact another attorney or file a complaint with the California Department of Fair Employment and Housing immediately, at (213) 439-6799. This office handles claims of discrimination and/or harassment based on race, age, sex, pregnancy, religion, national origin, sexual orientation, disability (ADA), Medical Leave of Absence, or retaliation cases where you were fired for opposing any of the above types of discrimination or harassment. Additionally, we handle those cases where you believe you were fired for refusing to engage in an illegal act(s), or for reporting, protesting or complaining about unlawful activity, unpaid wages or overtime, unsafe work conditions, and or fraudulent activity.
1.	Your First Name:
	Your Last Name:
	Home Phone:
	Work Phone:
	E-mail:
	Address:
	City: St: Zip:
2.	Current Employer:
3.	Date current employment obtained
4.	You are seeking advice regarding your employment at:
	(If terminated, list former employer here) Empoyer’s Name:
5.	Address of former employer:
6.	What type of business is the employer in? (about whom you are seeking advice)
7.	How many employees work in the company?
8.	If you know, provide your best estimate as to the employer’s profitability or gross monthly or annual sales($):

A. G E N E R A L I N F O R M A T I O N

1.	When were you hired at that company that fired, harassed or discriminated against you?
2.	When were you fired?
3.	Your title when you were hired:
4.	What is your current salary or the salary when you were terminated:
5.	Your supervisor’s name and title:
6.	Do you have a written employment contract? YES NO
7.	Have you ever been told that you can only be fired for "good cause?" YES NO Explain in detail what you were told and identify the person with whom you had the discussion:
8.	Does the company have an employee handbook or manual that provides for progressive discipline? YES NO I don't know
9.	Does the employee handbook or manual state that your employment is "at will" and that you may be fired for any reason? YES NO I don't know
10.	Have you signed a form stating that you agree to submit all disputes related to your employment to arbitration? YES NO I don't know
11.	Are you a member of a Union? YES NO
12.	Have you filed a grievance with your union regarding this problem? YES NO

B. N A T U R E O F D I S P U T E

13.	What is your complaint?
	Termination Discrimination Forced Resignation Harassment Demotion Failure to Promote Suspension (disciplinary action short of termination) Retaliation Other: Whistleblowing (Check here if you feel that you were terminated, harassed, or demoted in part because you refused to violate the law, protested violations of law, protested unsafe work conditions, complained about non-payment of wages or overtime, or complained about discrimination or harassment of yourself or another employee. If you protested or opposed discrimination or harassment, please state the type of discrimination and/or harassment about which you were complaining: [SEX, GENDER, SEXUAL ORIENTATION, AGE, RACE, RELIGION, NATIONAL ORIGIN, MENTAL OR PHYSICAL DISABILITY, PREGNANCY, OR REQUESTING MEDICAL LEAVE])
14.	If terminated, state what the Company said its reasons were for terminating you. (If you were told it was a layoff, state the reason the company gave for selecting you for layoff instead of other employees that hold the same or similar positions):
15.	If terminated, please explain what you believe was the actual reason that the company terminated you. (If you believe the company truly reduced its workforce, and eliminated one or more positions, please explain why you think they chose you for layoff instead of other employees that hold the same or similar positions. In other words, we want to know what you think the motive was, not what the company told you its reasons were.)
16.	If you were laid off, pursuant to a reduction in force, please list each employee that held a position similar to yours that was retained by the company when you were laid off. If your claim is discrimination based on age, race, gender, national origin, etc…, please also state the age, race, gender, or national origin of the employees that were retained. For each such employee, please also explain why you think that employee should have been laid off instead of you. For example, if you were laid off over an employee that had less seniority, less experience, less education or training, state that next to that employee’s name (BE SPECIFIC).
17.	If your employer told you that it fired you for violating some company policy, or disciplinary rule, or regulation (e.g., absenteeism, tardiness, theft, timecard fraud, unsafe workplace conduct etc…), please list each and every other employee that you believe engaged in conduct of the same severity and frequency, but was not fired. If your claim is discrimination based on age, race, gender, national origin, etc…, please also state the age, race, gender, or national origin of the employees that were retained. If your claim is based on whistleblowing, please state whether the employees that were not disciplined as severely as you also engaged in whistleblowing. Also state what misconduct each of the listed employees actually engaged in, when, how frequently, and the name of any supervisors that knew the employee committed the misconduct that you contend was as severe as that for which you were fired.
18.	Please list any supervisors or managers to whom you complained about discrimination, harassment or whistleblowing, including the dates of all such complaints. Be sure to state whether the complaints were oral or written and, if written, whether you have a copy.
19.	Did your employer follow company policy and procedure in handling your dispute? YES NO I don't know
20.	Do you feel you were treated differently from other employees in similar circumstances? YES NO I don't know If “yes”, please explain ”
21.	Do you feel race, age, sex, national origin, religion, sexual orientation, medical condition, taking medical leave of absence, pregnancy, or disability (physical or mental) was the cause of this difference in treatment? YES NO I don't know If so, why?
22.	If you believe that any of the above-listed characteristics might have motivated the employment action taken, please describe in detail, each and every fact upon which you base that conclusion. Possible evidence may include the following: (a) Statements or remarks by management: Examples of possible evidence of racial motive include, racial comments, stereotypes, jokes or comments by management, or comments by co-workers, of which management knew about. Also comments that you are not a “team player” might indicate a retaliatory motive. (b) Others were treated more favorably in similar situations: If other employees who did not have your protected characteristic (were not of the same race, age, gender, or were not disabled), were in treated better in similar situations, that may show discriminatory motive. For example, if you are a woman and were fired for being late, the fact that other male employees were also late but were not fired, would constitute evidence of discrimination. (c) Statistics: How many total employees at your company vs. how many employees of your gender, race, age or national origin. For example, if your company has only 2% Latino employees, but 25% of the applicants are Latino, that would tend to prove racism. Also, if Latinos, or women, or older workers make up only 10% of the workers at your company, but 50% of the terminations or suspensions, that would tend to support an inference that the terminations or suspension decisions were motivated by some protected characteristic.
23.	List the name address and telephone number, if available, of any witnesses to incidents described above:
24.	List the names of any other employees (current or former) who you believe have been treated like you?
25.	Describe any documents that you believe support your case?

C. W O R K P E R F O R M A N C E

26.	Was your work performance evaluated in writing? If so, please state the date of each evaluation and the overall rating you received. If please indicate whether you have copies of each evaluation.
27.	Have you received any commendations, letters or memos telling you that you were doing a good Job?
28.	Have your ever been disciplined, counseled, or warned about deficiencies in your work performance or violations of company policy at any time during your employment? If so, please state the date of each incident, the discipline imposed, the conduct for which you were disciplined and state whether you told your employer that you agreed or disagreed with the disciplinary action taken. Please provide all documents related to these incidents, including the write-up and memos, if they exist.
29.	Have you ever been terminated or asked to resign from employment before? YES NO If so, please describe, including the reasons given for your termination?

D. S T E P S T O R E S O L V E Y O U R D I S P U T E

30.	Did you inform anyone in management of your complaint? YES NO If so, state the date, name and title, of the person you informed and what actions were taken, if any, to resolve your complaint.
31.	Does your company have an internal complaint procedure? YES NO If so, did you file a complaint? YES NO When? What was the result?
32.	Have you filed a Union grievance? YES NO What happened?
33.	Have you filed a charge with the U.S. Equal Employment Opportunity Commission (EEOC)? YES NO When? What happened?
34.	Have you filed a charge of discrimination, harassment or retaliation with the California Department of Fair Employment and Housing? YES NO When? What happened?
35.	Do you have a copy of any charge filed with the EEOC or the Department of Fair Employment and Housing? YES NO If so, please attach copies.
36.	Have you received a “Right to Sue” letter? YES NO When?
37.	If terminated, have you applied for unemployment benefits? YES NO When? Result?
38.	Did anyone appeal the initial decision of the unemployment office? YES NO If so, who appealed?
39.	Have you examined your personnel file? YES NO If so, briefly state any fact of importance contained in or missing from your personnel file:

E. F I N A N C I A L A N D E M O T I O N A L E F F E C T S O F T H E D I S P U T E

40.	Describe the effect of your discharge or other action taken against you by your employer on your income; medical or pension benefits; profit sharing; or other financial impact:
41.	Describe the effects of your discharge or other action taken against you by your employer on your health and/or personal life, family relations, and opportunities for other employment?
42.	Have you sought any medical treatment or counseling because of your employment problems? YES NO If so, describe: A. Identify which of the emotional problems you now have that you had before the incident that caused you to seek legal counsel. In other words, which problems did you have before the harassment or discrimination even took place. Be sure to think carefully about this question because the defendant will subpoena all records from doctors, therapists or psychiatrists to determine whether you already had any or all problems you claim were caused by the defendant. F. PRIOR CIVIL OR CRIMINAL LITIGATION OR CLAIMS 39. Have you ever complained to any employer, formally or informally, orally or in writing, about harassment or discrimination, or filed any other discrimination complaint against this employer or any other previous employer, with either the company or the EEOC of the Department of Fair Employment and Housing? If so, please describe the nature of the complaint and how it was resolved.

F. P R I O R C I V I L O R C R I M I N A L L I T I G A T I O N O R C L A I M S

43.	Have you ever complained to any employer, formally or informally, orally or in writing, about harassment or discrimination, or filed any other discrimination complaint against this employer or any other previous employer, with either the company or the EEOC of the Department of Fair Employment and Housing? YES NO If so, please describe the nature of the complaint and how it was resolved.
44.	Have you ever filed a lawsuit before or have you ever been sued before? YES NO If so, please explain:
45.	Have you ever filed for bankruptcy before, or are you considering filing bankruptcy in the near future? YES NO If so, please state the date you filed and the result, (or state the date you are planning on filing bankruptcy. (**Note – if you are planning on filing bankruptcy anytime soon do not sign or file any bankruptcy documents without consulting with this office first, as filing a bankruptcy action could result in the termination of your lawsuit**)
46.	Have you ever been arrested? YES NO If so, please state the date, the charge/s and whether you were convicted.
47.	Have you ever filed a worker’s compensation claim for any injuries sustained at work? YES NO If so, state the date of complaint and the result?
48.	Are you a U.S. Citizen? YES NO If not, are you residing in the country illegally? YES NO
49.	Do you have a valid permit from the INS to work in the U.S.? YES NO If not, what does your employer know about your immigration status?
50.	What information did you check when you filled out the INS I-9 Form when your employment began?
51.	Since your termination, have you looked for other employment? YES NO If so, please describe your efforts, including dates, the name of the employer from whom you sought employment, and what the result?