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Please fill out this form as much as you can.

Your Name*

First Last

Your Current Address*

Street Address Address Line 2 City State ZIP Code

Your Email*

Your Phone Number

Your Age*

Identify the employer with whom you have a problem.*

State the employer's physical address where you worked.*

How large is the employer?*

1-5 employees
6-50 employees
More than 50 employees

When did you start working for the employer?*

When was your actual last day of work?*

Describe your job duties.*

Describe your compensation structure.*

What was your hourly rate during the last pay period?

What is your annual gross compensation?

Less than $50,000
$50,000 - $100,000
More than $100,000

What was your classification?*

I was classified as an employee and employment taxes were deducted from my paycheck.
I was classified as an independent contractor and received a 1099 form.
I was classified as an employee and independent contractor.
Not sure.

Are you a member of a union?*

Yes, I am a member of a union.
No.
Not sure.

Questions Related to Discrimination or Retaliation

Do you believe you were discriminated or retaliated by the employer?*

Yes
No
Not sure

If you believe you were discriminated/retaliated, state the basis of such discrimination/retaliation:

Race, ethnicity, or country of origin
Complaining about or objecting to unlawful activities
Disability
Taking sick day to care for myself or family member
Age
Sex, gender, or sexual orientation
Pregnancy
other

Please describe the "other" basis for discrimination or retaliation:

Please describe in details all incidents that you believe were discriminatory/retaliatory:

Did you complain about discrimination or retaliation to your superiors?

Yes
No
Not Sure

Check all that apply to you:

I was terminated or forced to quit as a result of discrimination/retaliation.
I was demoted as a result of discrimination/retaliation.
My compensation was reduced as a result of discrimination/retaliation.
My work hours were reduced as a result of discrimination/retaliation.
Other

Describe all "other" forms of adverse employment action taken against you as a result of discrimination/retaliation:

Questions Related to Unpaid Wages/Compensation

Do you believe you are owed any wages/compensation for work performed during the past four years?*

Yes
No

State all facts why you believe you are owed wages/compensation.

Do you believe you worked overtime hours for which you were not compensated?

Yes
No

State all facts why you believe you are owed overtime:

Do you believe your employer failed to provide you with an opportunity to take a 30-minute "off-duty" meal break within first 5 hours of work?

Yes, I believe my employer violated my meal break rights.
No, all meal breaks were provided every 5 hours.

State all facts why you believe your meal break rights were violated.

Do you believe your employer failed to provide you with an opportunity to take a 10-minute "off-duty" rest break every 4 hours of work?

Yes, I believe my employer violated my rest break rights.
No, I received all rest breaks every 4 hours.

State all facts why you believe your rest break rights were violated.

Do you believe you had work-related expenses for which you were not reimbursed (e.g. mileage, office supplies, cell phone, etc.)?

Yes
No

Do you believe some of your work hours (or assignments) were excluded from compensation (e.g. travel time, waiting time, pre/post shift inspections, cleaning,etc.)?

Yes
No

State all facts why you believe some of your work hours (or assignments) were not paid by your employer.

Do you have an attorney who currently represents you in this matter?*

No
Yes

Who is your attorney?

Please add any additional information that may help us to evaluate your case.

Consent*

I agree to the below terms.

By submitting this form you acknowledge and understand that the use of this form in no way creates an attorney-client relationship with Klein Law Group, LLP or its attorneys. An attorney-client relationship will only come into being between you and Klein Law Group, LLP only if you and Klein Law Group, LLP enter into a written fee agreement that is prepared by Klein Law Group, LLP. If you have any questions regarding this disclaimer please contact our office at (415) 693-9107.

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Employment Law Questionnaire

Klein Law Group, LLP

Please fill out this form as much as you can.

Questions Related to Discrimination or Retaliation

Questions Related to Unpaid Wages/Compensation