test 2 [grw id=”256″] Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstLastPhone Number (with area code) *Email *County where you are or were employed *State of employment *State where you reside *Where did/do you work (name of business/organization) *Are you currently employed (Yes or No) *YesNoDate of Harm (Termination, Harassment, Cut Pay, Etc) *Do 12 or more employees work for the company (if you work for a government entity select yes) (Yes or No) *YesNoList the known name of any person who made a decision affecting your employment (can be a Human Resources professional, owner, manager, co-worker, etc) *What state does that person reside in (if unknown please use the state wherein you reside) *Are you a member of a protected class based on any of the following – select one or more: *Age (over 40)AncestryRace/ColorEthnicityReligionNational OriginVeteran StatusCreedGender/SexGender Identity or ExpressionGenetic InformationHIV/AIDS or other sexually transmitted diseases (Confidential)Sexually HarassedSexual OrientationTake Paternity or Maternity leavePregnantDisabled/disabilityUnequal PayLGBTQIA+Prior known drug usage/substance addictionOut on Sick LeaveFiled for Sick Leave (FMLA or other)Are you related to or did you advocate on behalf of any person who fits one or more of these options?Experience a workplace injury or file Workman’s Compensation ClaimNone of these apply to meDo you feel you were retaliated against for complaints about one or more of the following (select all that apply): *Complaints about workplace safetyComplaints about ethicsComplaints about wrongful spending or billing practicesComplaints about patient safety (medical professionals)Complaints about overcharges to customers or failure to provide services, overbilling, etc.Complaints about unequal pay, unfair pay, or not getting paid on timeComplaints to HR about managementComplaints about unsafe productsComplaints to any government agencyComplaints about fraud or dishonestyComplaints about privacy concernsComplaints about regulation of business and non-complianceComplaints of any criminal conduct or alleged criminal conductFiled or could have filed a Workman’s Compensation ClaimMade “whistleblower” type claim or complaintComplaints about employer violating an agreement or contractExercising rights afforded to veteransComplaints about voting or political concernsIssues with Drug TestingDisciplined or fired for “non-work related” requirements such as duties outside your job description or forced to come in on days offIssues with a truthful statement you provide in any investigation or legal matterRetaliated against due to self-protectionRetaliated against for filing a grievanceConstitutional right claimComplaints about equal pay or protectionRetaliated against for poor credit or garnished wagesAnother form of retaliation not listedNone of these apply to meHave you been paid all wages due timely (Yes or No) *YesNoDo you feel you were paid less than others in the same position (yes or no) *YesNoWere you sexually harassed (Yes or No) YesNoDo you have documents supporting your claims (text, messages, screenshots, social media posts, etc.) (do not lose this data, it can harm your claim) (Yes or No) *YesNoINFORMATION PROVIDED BELOW THIS FIELD IS OPTIONALDo not fill in this feildWays that you can prove discrimination or retaliation, check all that apply. Your employer changed the reason for your termination or other adverse action (for example, the employer claimed you were fired for missing too much work but then changed the reason to performance reviews)Inconsistent reasons for the terminationCompletely invalid or impossible reason for the termination or other harmComparator data – others were treated differently than you. Such as you were written up for being five minutes late but others were late as well and did not get written up.Delay in reason – such as never being told your work was an issue until after you had to be out for medical leave. Or not told about client complaints, etc.Set up for failure, not trained, etc.Employer ignored policy or progressive disciplinary policy in your terminationIrregularities in … the procedures for dischargeComplete disbelief of the company or organization’s reasoningFailure to document – if the employer failed to document reasons for termination and was required to document by the policy.Lying in Wait – employer waited for some legitimate reasons to materialize to cover up bias or longstanding discriminationYour performance history was good/greatThe person that replaced was not qualifiedYou received more severe punishment than othersShoddy Investigation – the investigation is highly suspectTermination was not based on subjective criteriaMade up stories or lies about youInterfered in your job performance, but not othersTiming – you were not disciplined for any actions until shortly after you filed a complaint or discussed disability, leave, etc.How were you harmedFiredLoss of hoursCut in pay or bonusForced to relocateLabeled “do not rehire”Unequal pay/benifitsUnfair performance reviewsExchange of more important assignments with less important onesDemotionDenying or removing privileges of employment (i.e., overtime)Unfair warnings and disciplineNot providing documents and/or information necessary for an employee to competently do his/her jobBarring employee from trainingExcluding employee from meetings, conferences, etc.Labeling employee as “a troublemaker” to managers and supervisors in employee’s groupRefusing a transfer and badmouthing to potential managers about employee’s “bad” performanceAssigning an employee duties that fall outside of employee’s job descriptionStripping employee of supervisory dutiesDisproportionate reduction of workload and pay (i.e., no overtime)Embarrassing the employee in front of subordinatesUndermining the employee by removing important contracts or territoriesForcing the employee to train the subordinate and then promoting the subordinate and not the employee who did the trainingAccusing employee of being confrontationalDisclosing confidential information about employees to co-workersTelling the employee to forget about a promotion or a raiseHave you filed a claim for unemployment benefits (yes/no)YesNoHas your employer appealed or "fought" your unemployment claim (yes/no/unsure)YesNoUnsureHave you filed a claim with EEOC or any Human Rights Comission (yes/no)YesNoWhat was your rate of payDid you get benifits (yes/no)YesNoHas the job situation caused any repossession, eviction, or loss of services (yes/no)YesNoHave your received medical attention related to anxiety, depression, stress, or other impairment related to your employment situation (yes/no)YesNoSubmit
