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Your name
Your address
Your phone numbers
Your email
Are you currently employed?
Name of current / former employer?
What was your job title?
What was your salary?
Date hired
Date fired/quit/laid off
If terminated:
Reasons given for termination:
Real reason for termination:
Do you feel you suffered retaliation?
If so, please describe:
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Date of retaliation:
If disciplined, action taken:
Date of disciplinary action:
Reasons given:
Real reason for discipline:
Did you complain to other people (i.e. Human Resources, your supervisor’s supervisor, other supervisor, etc.) about your treatment?
Date(s) of complaint(s):
Was there an investigation?
What was the result of the investigation?
Other information/general questions:
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