Office Use Only:To show the hidden 'Office Use Only' fields, the password is office This message is only shown during testing.Schedule InterviewDate Rejected Referred ToName of Person Doing IntakeDate of Intake* Name* First Last Email Home PhoneCell PhoneFAXWhat Is Your Age?What Race Do You Identify With?*African American / African / Black / CaribbeanAsian / Pacific IslanderCaucasian / WhiteHispanic / LatinoNative AmericanPrefer not to answerHow Were You Referred To Our Office?*Google (what keywords), Attorney name, etc.Complaint InformationName and Address of Employer With Which You Are Having A Dispute*Your Position / Job TitleWhat Were Your Job Duties?*What Is Your Complaint?*Why did your employer take adverse employment action? Is it based on your age, sex, sexual orientation, race, disability, religion, complaints about illegal activity, or protesting harassment or sexual harassment? Were you retaliated against because you complained about something? Please explain complaint and retaliatory actions.Date of Hire Date Harassment Began Date of Employment Termination (If applicable; Fired / Quit / Still Employed / On Leave)Did You Have Any Write-Ups or Disciplinary Action?If Yes, Why And How Many?What Is/Was Your Monthly Average Income? Hourly Pay?*What Was The Last Day You Worked? If applicable. If unsure, please choose closest date.Did You Take Any Medical, Pregnancy or Disability Leave?*If yes, what kind? Please include dates.Have You Filed Anything With The DFEH or The EEOC?*DFEH = Department of Fair Employment and Housing, EEOC = Equal Employment Opportunity Commission (Please list dates and outcome.)Do You Have A Current Workers' Compensation Suit or Have You Ever Filed One?*Please include dates and outcome.How Many Employees Work At The Location Of Your Employer?*1 - 55 - 1010 - 2020 - 5050 +How Many Employees Work In The Entire Company?*1 - 55 - 1010 - 2020 - 5050 +How Many Offices In California?*12345 or MoreIs There A High Turnover At The Company?*Are People Being Hired and Fired/Quitting Often?Are You Part Of A Union?*YesNoWage And Hour ClaimsWere You Hourly or Salaried or an Independent Contractor?*HourlySalaryIndependent ContractorWhat Was Your Work Schedule?*Please list days and hours.How Did You Clock In/Out For Work?*Did you do it or did someone else?Meal Period*Given 30 minute break before 5th and 10th hours? Were You Ever Interrupted?Rest Period*Given 10 minute break for every 3.5 hours worked? Were You Ever Interrupted?What Do You Do Before Your Shift To Get Ready?*How much time is spent and are you on the clock during?What Do You Do At The End Of Your Shift Before You Leave?*How much time is spent on the clock?Off The Clock Work*Have you ever worked off the clock? Why?Overtime*How often worked and pay rate?Do You Earn Commission/Bonus?*How often and how much and IF you get commissions, is it factored into the overtime rate?How Often Paid?*Was it ever late?Ever Paid Without A Pay Stub?*Ever Paid Less Than The Applicable Minimum Wage?*How often, how much and why?Vacation*Are they provided paid vacation and has employer ever taken earned vacation time away?Uniform*What is it and have you ever had to pay out-of-pocket for it?Business Related Expenses*What are they and are you reimbursed for any expenses you forward?How Were You Paid?*Paycheck or cash?If Paid By Check, Could You Cash With Any Bank?*If not, were you ever charged to cash your check?Deductions From Paycheck?Do they ever deduct costs for running the business?When Did You Receive Your Final Paycheck?Terminated - day of? Resign - 3 days?Office UseClient's DemeanorArticulate, Sympathetic, etc.Date Reviewed InitialsInterview / DeclinedReferredWhyCAPTCHACommentsThis field is for validation purposes and should be left unchanged. Save and Continue Later This iframe contains the logic required to handle Ajax powered Gravity Forms.