General Employment Questionnaire Please Note: Due to many frequent spam form submissions, we have added captchas to all of our forms. If you forget to fill out the captcha at the bottom of the form, just hit your browser's back button. This should take you back to the version of the form that had all the information filled out. You can then fill out the captcha at the bottom of the form. Also, you may always call us if you prefer.Your NameTelephone Number(s)Email AddressHome AddressCity, State, Zip CodeEmployerHow did you hear about us?phone bookanother attorneybar associationotherGeneral Employment QuestionnaireThe following questions try to get specific information on your employment claim. Check the boxes which apply and try to provide as much detail as possible.Please note there is no limit to the amount of information you can enter. The boxes will scroll as necessary as you add additional information.How has your employer harmed or injured you? What problems do you have at work?If you were fired or disciplined, what was the date and the reason given, and were you given anything in writing?Why do you feel your employer did this to you?AgeSex (including harassment)RaceNational OriginReligionMedical/DisabilityHostile Work EnvironmentConstitutional ClaimsOtherIf other, please briefly describe.How many employees does the company/employer have?Have you contacted the EEOC or the New Mexico Human Rights Division (HRD) regarding your complaint?YesNoIf yes, when?Have you filed a formal charge with the EEOC or HRD?YesNoIf you were fired, have you applied for unemployment compensation?YesNoYour employmentDate of HireJob Title at HirePerson who hired youWere there any documents exchanged during hiring, such as a hiring letter, a written employment contract, an employee handbook, or policy manual?YesNoIf there were any promises, oral or written, made at the time of hiring, what was promised?Were these promises fulfilled?YesNoWere there any promises of employment or job security?YesNoDescribe your job progression at the company:Number of Promotions:Job Title and Pay Rate at Discharge:Your immediate supervisor's name, title, age, gender, and race:What action did the employer take against you (termination, loss of promotion, etc.), and when?What reason were you given for the action that was taken against you? If not true, what was the real reason?Job Performance ReviewsIf you received written performance evaluations, how often were you evaluated, by whom, and what was your most recent rating?If you have received any oral and/or written warnings or reprimands, what was the reason given by employer?Potential WitnessesPlease list any person who might have personal knowledge of your problems/complaints. Please include their names, addresses, telephone number (work and/or home), and what position they held or continue to hold with your employer. Please indicate precisely what information they can provide or corroborate.Are there any others in your immediate work area who are being treated similarly to you?YesNoIf you know anyone who would/might act as a witness against you, please provide details (who, what they might say, etc).Does your employer have an internal grievance procedure?YesNoIf yes, did you follow this procedure?YesNoOther EvidencePlease describe any written information or documents which might support the claim you have. Include any letters, job description, employee handbooks, performance evaluations, etc. Please provide a copy of any material you list to our office for further evaluation.If you were terminated, were you asked to sign a release agreement?YesNoIf yes, do you have a copy?YesNoPlease identify any records, statements, photographs, documents, or written evidence your employer may have which could affect your claim such as performance evaluations or disciplinary letters or notes of conversations.If there is any information on your application for employment which is inaccurate or misleading, please describe:If you have been involved in any other lawsuits or made any previous complaints of discrimination regarding any prior employer, please describe.If you have a criminal record of any sort (e.g., if you have ever been arrested or convicted for any crime, misdemeanor or felony), what was the nature of the arrest or conviction?What are your goals? (If the answer is a specific monetary amount, please describe how you arrived at that amount)DamagesThe law requires that you must try to cut your losses by trying to get comparable work.Briefly describe your efforts to find new work.Have you found other employment?YesNoIn addition to salary, if you have lost any fringe benefits such as health insurance or pension, please describe:If you are claiming that you were unlawfully denied a promotion, state the amount of increase and other benefits you would have gotten.If you were fired, and you have made any money (wages, contracts, etc) since, how much, when, and from whom?If you were fired and have been physically or mentally unable to work, please state the dates and reasons:If you have suffered any physical or emotional harm because of your employer's action, please describe the harm, any medical treatment (including therapy), the date of treatment, and the name and address of the treating professional (doctor, psychiatrist, psychologist, therapist, etc).Please add any other information you feel is important.