Labor Intake Questionnaire - Florin Roebig // Trial Attorneys

All fields are required for submission. If a question does not apply to you, please enter “not applicable”.

First & Last Name

Phone

Street Address

City

State

ZIP Code

Date of Birth

Sex

Male

Female

Ethnicity

Who is your employer?

What is/was your job title/position and what were your job duties?

What is/was your salary/wages?

How many employees work/worked at your location? At your employer as a whole?

What were the dates of your employment (start and end date)?

Who hired you and what was their job title/position?

Do you feel you were discriminated against? If so, on what basis? (sex, race, age, religion, national origin, disability, pregnancy, FMLA)

Do you feel you were retaliated against? If so, on what basis?

Do you believe your employer is/was engaging in illegal conduct? Did you object to it or report it? If so, to whom?

Please describe the issue you had/are having with your employer which has prompted you to seek legal representation, including all relevant dates and names:

Did your employer provide you with performance evaluations/feedback? If so, please describe them.

Have you ever received any write ups or other disciplinary action by your employer? If so, please describe them, including the date(s) you received each write up or disciplinary action.

Are you still employed, have you resigned, or have you been terminated?

If you were terminated or forced to resign, who terminated you and what was their position, age, sex, and ethnicity?

If you were terminated, what was the reason your employer gave you?

Has your position been filled? If so, what is the age, sex and ethnicity of your replacement?

If you’ve been terminated, have you found new employment? If so, please list the name of your new employer, your job title, the date you were hired, and your current income.

Please list any individuals that may be able to provide information relevant to your claim, including whether they are a current or former employee, and what information they have:

Were you referred to our practice? Referred by:

Intake Form: Labor Law