Employment Discrimination

Employment Discrimination Intake Form
Full Legal Name

Date of Birth *

Religion

Home Phone *

Email Address *
Gender *

Male Female

Race/Nationality *

Address *

Work Phone

Former Name(s) *
Marital Status *

Single Married Widowed Divorced
Children
Full Name

Name

Name

Full Name
Date of Birth

Date of Birth

Date of Birth

Date of Birth
Living at Home?

Living at Home?

Living at Home?

Living at Home?
Details
Employer at Time of Discrimination or Harassment *

Employer’s Address *

Hire Date *

Explanation given for your termination *

Gross Monthly Income at Time of Termination *

Benefits Provided by Employer *
Job Title at Time of Discrimination/Harassment *

Length of Time with Employer *

Termination Date *

Previous Employer(s) (for last 10 years) *

Other Income at Time of Termination *

Date(s) of Harassment or Discrimination *
Description of Harassing or Discriminatory Actions Taken Against You
Was anyone else treated similarly *
If Yes, who? Please include race and gender *
Who harassed you or discriminated against you? *

Is he or she considered to be your supervisor? *

Who was your immediate supervisor at the time? *

If Yes, to whom? *

Was a written report made? *

Were you ever given an employee handbook? *

If Yes, does it contain an anti-harassment or anti-discrimination policy? *

Since the harassment or discrimination, have you spoken or had any contact with the person who harassed you or discriminated against you? *
What is that person’s job title or description? *

Was anyone else present at the time of the discriminatory or harassing act? *

Did you report the harassment or discrimination to anyone? *

What was their response? *

If Yes, do you have a copy of it? *

Do you have a copy of it? *

Have you ever seen a copy of an anti-harassment or anti-discrimination policy in your workplace? If Yes, explain: *

If Yes, explain *
Have you ever been disciplined by your employer, for any reason? If Yes, explain *
Have you ever been harassed or discriminated against in other employment? IfYes, explain *

If Yes, what was the outcome? *

Name of Present Employer *

Current Immediate Supervisor *

Current Gross Monthly Income *
Was a lawsuit filed? *

If you were terminated or left your employment, have you found a new job? *

Address of Present Employer *

Current Job Position/Title *

Benefits Provided by Current Employer *
Have you ever been told that you have a physical or mental disability? If Yes, explain

Other Important Information *
DISCLAIMER: The information contained and requested on these pages is intended to provide general information only. Completing this Intake Form does not create an attorney-client relationship. Please contact our office with questions.

Employment Discrimination Intake Form

Children

Details

Office :

150 S. Wacker, 24th Floor Chicago, IL 60606