Please describe your job duties.
What is the name and address (city, state) of the company (or
government agency) where you work(ed)?
Please give a brief account of your complaint, including the
date, place and other persons involved, if any. Include the
nature of the job action taken against you (for example, harassment,
termination, loss of promotion, hostile work environment).
What reason were you given for the action that was taken against
you?
What do you believe was the real reason for the adverse job
action if the reason given is inaccurate?
Have you ever received any verbal and/or written warnings or
reprimands? If so, explain.
Did you receive written performance evaluations? If so, what
was your evaluation or rating?
If the adverse job action was taken by a co-worker, have you
reported that conduct to a supervisor or to anyone else within
the company? If yes, when and to whom did you report, and how
did the company respond to your report?
Do you know whether your employer has an internal grievance
procedure? If yes, did you follow this procedure?
Please identify any records, statements, photographs, documents,
or written evidence your employer may have which would affect
your claim such as performance evaluations or disciplinary letters
or notes of conversations.
Have you ever worked more than 40 hours in a single week?
If so, have you been paid time and a half for overtime?
Yes
No
Are you paid time and a half for all overtime hours worked,
even if the hours were not pre-approved?
Yes
No
If you claim that your reputation or your ability to obtain
a job in your field has been damaged as a result of the employer’s
conduct, please describe.
Have you contacted any government agency (for example, the
EEOC, NY Division of Human Rights, NYC Human Rights Commission,
Department of Labor) regarding your complaint? If so, when?
Please describe any witnesses, written information or documents
which might support your claim. Include any letters, job description,
employee handbooks, performance evaluations, etc.
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