Initial Questionnaire | Jackson Spencer Law, pllc All fields required unless marked 'opt' for optional. After submitting this form, you should receive a confirmation email. If you do not, please call our team at (972) 301 - 2937 [M-F 9-6]. Thank you. What is your name? What is your phone number? What is your age? What is your race/national origin? What is your gender? What is your religion? (opt) What is the name of the company that is involved in your matter? In what city do/did you work? About how many people does this company employ? —Please choose an option—Under 15 employees15-30 employees30-50 employees50-100 employees100-500 employees500+ employeesUnknown When did you start working at this company? (MM/YYYY or MM/DD/YYYY) What type of work do you/did you perform? Does your company fit into the following list of industries? If so, please select the closest option. If not, select other. —Please choose an option—EducationFood IndustryFinanceMedicalProductionInsuranceGovernmentSecurityOil and GasUtilitiesRetailTechnologyOther At tax time, does your employer send you a W2 form or a 1099 form? Select oneW21099 What is your rate of pay? (yearly is preferred) How much additional (if any) do you earn in commissions/bonuses/tips? Did you/do you work full time at this job? YesNo If not, how many hours per week, on average, did you work over the last 12 months? Have you reported industrial or medical hazards to a supervisor, manager, or government agency? Yes, in the last 30 daysYes, more than 30 days agoNo If yes, please describe: Have you made a complaint to OSHA or the Department of Labor? If so, please provide a copy of the complaint and any response to it by replying to the email you received from us with a downloadable attachment. YesNo Have you recently taken time off due to a medical condition for yourself or a family member? YesNo If yes, please describe: Do you have any medical conditions or disabilities which require accommodations at work? If so, please provide details: Have you submitted any information to the Equal Employment Opportunity Commission about this matter? YesNo Have you had an interview with the EEOC? YesNo Have you submitted any information to the Civil Rights Division of the Texas Workforce Commission (not Unemployment) about this matter? YesNo Have you had an interview with the Civil Rights Division? YesNo Have you received a "Notice of Dismissal," "Right to Sue," or "Notice of Rights" letter from any government agency about this matter? YesNo If you answered YES to any of the above five (5) questions, please send a copy of your documentation by replying to the email you received from us containing the link to this questionnaire and attaching it there. This includes but is not limited to your Initial Inquiry, Charge of Discrimination, Invitation to Mediate, Notice of Dismissal or Right to Sue. Our attorneys need to see this documentation in order to best determine how to help you. How did you find our firm? If you used a search engine, what did you search (e.g. "employment lawyer")? Please answer the questions in ONE of the following FOUR categories: Option 1: I was terminated Date you were informed of your termination? (MM/DD/YYYY) Your last day of work? (MM/DD/YYYY) Who terminated you? (name/position) Is that the same person that hired you or did that person have a hand in hiring you? What was the company's stated reason for your termination? If different from the company's stated reason, why do you think you were terminated? Why do you think they terminated you when they did? Did you have a sense that you would be terminated or were you taken by surprise? If you saw it coming, when did you notice it, and what changed? If available, please send a copy of your termination letter to us. Attach it in a reply to the email that you received the link to this questionnaire in. Were you offered severance? (yes/no) If so, how much? What is your deadline to sign and/or accept? If available, please send a copy of your severance offer to us. Attach it in a reply to the email that you received the link to this questionnaire in. Option 2: I was suspended Date you were suspended? (MM/DD/YYYY) Were you suspended with or without pay? —Please choose an option—With payWithout pay Who suspended you? (name/position) Is that the same person that hired you or did that person have a hand in hiring you? What was the company's stated reason for your suspension? If different from the company's stated reason, why do you think you were suspended? Why do you think it happened when it did? Did you have a sense that something like this would happen or were you taken by surprise? If you saw it coming, when did you notice it, and what changed? Option 3: I resigned Date you resigned? (MM/DD/YYYY) What was the reason for your resignation? Please send a copy of your resignation letter to us. Attach it in a reply to the email that you received the link to this questionnaire in. Option 4: I am still employed What is your ideal resolution to your situation (move departments, would like to resign, etc.)? - - - - - - - - - - - - Have you ever been written up or placed on a performance improvement plan? YesNo If YES, please provide details. Include: who placed you on the PIP/gave you the write-up, and when; Do you feel like this PIP/write-up was fair or unfair? If unfair, describe why. Finally, please provide a brief background of your matter (Why did you reach out to us?): Would you like to opt-in to receive periodic text message updates (max 3 total text messages) about your intake inquiry with Jackson Spencer Law? We will not contact you after your intake inquiry is closed. Message and data rates may apply, reply STOP at any time to opt-out. Opt-in to SMSOpt-out of SMS