Tell Us Your Story

*Name:

*Home Address:

*Home Telephone:

*Cellular or Pager:

*Email Address at which we can securely contact you:

History at the Employer  (All questions from here on concern only the employer with whom you have a dispute)

Name of Employer with whom you have a dispute:

Web address of this Employer:

Street Address of this Employer:

(Please note that we only handle cases involving employment in Minnesota)

Employer Phone No. (at location where you worked):

Location of Employer Headquarters (city and state):

Dates of Your Employment:

Start   End     Still There

Current Status with the Employer:
 Terminated

 Quit

 Still There

If terminated what were the reasons you were given and how were they communicated to you (in writing, in person, over the telephone, etc.):

If you quit, please explain why you quit, what you told them about why you quit, whom you told and how you told them (in writing, in person, over the telephone, etc.):

If you are still there, what is your concern about this employer?

PriorDisciplinary History at this Employer:
Choose One Employer does not use corrective action None in last 5 years Only 1 corrective action in last 5 years More than 1 corrective action in last 5 years

If prior corrective actions in last 5 years, dates and explanations for each:

Job Performance History at this Employer

With respect to your job performance, check or complete all that apply.

 The overall rating on my most recent performance review was:

Employer does not give reviews Above average or exceeding expectations Average or meeting expectations Below average or needing improvement Not applicable

Date of the most recent review:

 I was given (or am on) a performance improvement plan

 I have received awards or special recognition in the past two years.

Chain of Command

Name and Title(s) of Supervisor(s) involved:

Name of any Human Resource representatives involved:

Tell Us Your Story

Please tell us below what has happened to you that has caused you to seek out a lawyer.  To the extent that you are able, please tell the story as completely as you can in chronological order, stating names and dates of key people and events to the extent you are able.

Key Witnesses

It is helpful if we know if you have witnesses that can support what you tell us.

Is there at least one supportive witness to what happened? (Please note that a supportive witness is someone who will probably testify that they directly saw or heard the some of the events you have described and can confirm your version of them.)

Choose One Yes No I don't know

If “yes”, please list the names of those who saw or heard your version of events, tell us if they currently work for the employer (and what their position is), what you think they observed, and if you believe they will talk to us about it. If you have addresses and telephone numbers for them, that may also be helpful. We will not, however, contact anyone without your knowledge and approval and it is possible that we may not contact anyone before making our assessment of your potential claims.

Key Documents

Is there at least one key document that supports your side of the story?

Choose One Yes No I don't know

If you have one or more documents, please tell us what the document(s) is/are that are key to your case.   If you have the ability to email them to us by separate email in a word processing or pdf format, or if you would like to send them to us by regular mail, please send them along with a short explanation.

Some Specific Types of Potential Claims

Were you (or are you) employed “at-will” by this employer?

Choose One Yes No I don't know

Were you (or are you) a member of a labor union at this employer?

 Yes  No

Did you have a written employment agreement or contract with this employer?

Choose One Yes No I don't know

Did this employer provide you with an employment handbook?

Choose One Yes No I don't remember

Do you believe you have been the victim of sexual harassment?

Choose One Yes No Possibly, I'm not sure

If “yes” or “possibly”, please explain what has happened that was sexual harassment and when it occurred (to the best of your recollection).

Do you believe that the employer involved has retaliated against you for reporting to the employer or the government any of the following?

Choose One Not Applicable Illegal Conduct Sexual Harassment Discrimination Violation of Company Policy Unsafe conditions Wage and Hour Law Violations Violation of Health Care Standard Other

Do you believe that your membership in any of the following protected classes had anything to do with your situation?

Choose the most likely one Not Applicable Age Sexual Harassment Race or color Religion or creed National origin Disability Sexual Orientation Status with regard to Public assistance Other

If you believe your protected class status was involved in decisions about you at work, please explain why and what your evidence would be.

Have you ever reported to the employer or to the government any suspected or actual violation of the law by the employer?

Choose One Yes No

If “yes”, please tell us about that.

Has the employer in question lied about you?
Choose One Yes No I don't know

If “yes”, tell us what about that.

Charges of Discrimination or Harassment with the Government

Have you filed any charge with the EEOC, the Minnesota Human Rights Department, or any local human rights agency concerning your situation?

Choose One Yes No

If you have filed a charge, your charge is:

Choose One Yes No

If you filed a charge and it was dismissed, what is the date on the dismissal notice?

Is there anything else you would like to add?

Choose One Yes No

If “yes”, what is it?