Intake Form B

Date:

*Name:

Home Phone:

Work Phone:

Cell Phone:

*Email Address:

Referred By:

1. Name of the company your claim is against:

Address:

Type of business:

Number of employees:

2. In what state do you:

WORK:
 Virginia (county )
 Maryland (county )
 District of Columbia (county )
 Other (county )

LIVE:
 Virginia (county )
 Maryland (county )
 District of Columbia (county )
 Other (county )

3. Position:

Salary:

4. How long have you worked there?

5. Are you being subject to a personnel action? (for example, leave restriction, denial of promotion, suspension, removal)

6. Is the personnel action described above proposed or taken?
 Proposed
 Taken

Date of notification (of decision actually taken):

7. BRIEFLY describe your employer's stated reason for taking the personnel action:

8. Have you begun an internal grievance process? (in other words, begun an appeal within the company):
 Yes
 No

IF YES,
-What date was the process initiated:

-What is the current status:

9. Are you alleging discrimination?
 Yes
 No

10. What is the basis of the discrimination? (Check all that apply):
 Sex
 Race
 National Origin
 Color
 Marital Status
 Other
 Disability
 Age
 Sexual Orientation
 Religion
 Reprisal

If Other Please Describe:

11. BRIEFLY describe the events which you believe were discriminatory:

12. Have you contacted the EEOC or other Human Rights Commission? (i.e., County or State):
 Yes
 No

IF YES, what is the current status?:

13. Have you begun any proceeding in any federal court related to the claim you are contacting us about?
 Yes
 No

IF YES, Date the request was filed:

What is the current status? (for example, have you received any orders from the judge? Has a hearing date been set?):

14. Are you facing any time deadlines related to ANY of the above claims?
 Yes
 No

IF YES, The date of the deadline is:

What is due by the deadline?:

15. Do you have an employment contract?
 Yes
 No

16. Does your company have an employee handbook/policy manual?
 Yes
 No

17. Are you covered under a union contract?
 Yes
 No

IF YES, name and Local No. of union:

18. If you are covered under a union contract, have you requested the Union's assistance with your problem or has the Union intervened on your behalf?
 Yes
 No

IF YES, Date the union was contacted on this matter:

BRIEFLY describe the union's role:

19. Current employment status:
 Working
 On administrative leave
 Terminated as of: 
 Suspended as of: 
 Other: 

20. If an attorney cannot call you back today within normal business hours, what is the latest time an attorney can call you at home?