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 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 (a range is fine if you do not know the exact number)?
When did you start working at this company? (MM/YYYY or MM/DD/YYYY)
What type of work do you/did you perform?
Are you a W2 or 1099 worker? W21099
What is your rate of pay? (yearly is preferred)
How much (if any) do you earn in commissions/bonuses?
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 any safety concerns to a supervisor, manager, or government agency in the past 30 days? YesNo
Have you recently taken time off due to a medical condition? YesNo
Have you recently taken time off due to a family member's medical condition? YesNo
Do you have any medical conditions or disability 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)
What was the company's stated reason for your termination?
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)
What was the company's stated reason for your suspension?
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.)?
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Finally, please provide a brief background of your matter (Why did you reach out to us?):
1. Your Name (required)
2. Your Email (required)
3. Phone (required)
Preferred contact:PhoneEmail
Please leave this field empty.
4. Employer
5. Dates of Employment
6. Job Title
7. Pay
8. Have you been terminated? If So, Please Give Details, Including Dates (required)
9. Which of the following below best describes why you believe you have been discriminated against or retaliated against? (required)-- Please select only one (1) choice, even if more apply --Age (above 40)Breach of contractColor, race, or national originDisability or request for disability accommodationGender, sex, and/or sexualityPregnancy or request for pregnancy accommodationReligion or request for religious accommodationMedical leave for myself or for a family memberMilitary/veteran status or military leaveTalking about pay at work or union activityWage issue: overtime violation, asked to work for freeWhistleblowing: safety or worker's compensationWhistleblowing: financial/fraudOther (please write in box below)
10. Your City (required)
11. Your State (required)AlaskaAlabamaArkansasArizonaCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMichiganMinnesotaMissouriMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWisconsinWest VirginiaWyomingDistrict of Columbia
12. Other Comments - Please provide a few specifics so we know if we're the right law firm to help you with your matter.
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