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CONTACT INQUIRY
Name
First
Phone
Email
Pronouns
Employer Name
Hire Date *
MM slash DD slash YYYY
Last date of incident
Termination Date (if applicable)
I was
Terminated
Demoted
Suspended
Forced to quit
Denied Reasonable Accommodations for Disability
Denied 12 Weeks of Family Care/Medical Leave
My Employer is a
Private Entity
Public Entity (e.g. state, federal, local, government, school district, or agency)
Non-Profit
Check this box if employer has 50 or more part or fulltime employees
Because of my
Race/Color
National Origin
Disability/Medical Condition
Sex/Gender
Transgender
Sexual Orientation
Age
I was harassed based on my
Race/Color
National Origin
Disability/Medical Condition
Sex/Gender
Transgender
Sexual Orientation
Age
Request for Reasonable Accommodations for Disabilities
Request for a Medical Leave of Absence for Self, Family or Bonding Leave
Retaliation/Whistleblower
Opposing/Reporting Discrimination/Harassment or Retaliation
Because I was Stalked by a Third Party
Because I was a Victim of Sexual Assault by a Third Party
Because I was a Victim of Domestic Abuse by a Third Party
Opposing Employer Policies
Refusal to Participate in Conduct by Employer
Reporting Conduct by Employer
Reporting Fraud, Waste or Abuse
Reporting a Workplace Injury
Relocated to Accept Employment Procured by Employer Misrepresentation
Blackballed by Former Employer from Obtaining New Employment
Complaints About Unfair Wages
Complaints About Fraudulent Accounting Activities by an Employer who is Public Traded
The Harassment was by a
Owner/President/Chief Executive (or Financial) Officer/Executive Director
Supervisor/Manager
Co-Worker
Subordinate Employee
Third Party
I Reported the Unlawful Conduct by My Employer on
MM slash DD slash YYYY
Please Detail Specific Facts and/or a Timeline of Discrimination, Harassment and/or Retaliation *
How did you hear about us? *
Dept. of Fair Employment & Housing
Equal Employment Opportunity Commission
CA Employment Lawyers Association
AIDS Legal Referral Panel
Private Attorney
Former Client
State Bar of CA
Union
Google (search engine)
Non-Profit
Other
Name *
Phone *
Email *
Pronouns *
Employer Name
Hire Date *
Last date of incident
Termination Date (if applicable)
I was
Terminated
Demoted
Suspended
Forced to quit
Denied Reasonable Accommodations for Disability
Denied 12 Weeks of Family Care/Medical Leave
My Employer is a *
Private Entity
Public Entity (e.g. state, federal, local, government, school district, or agency)
Non-Profit
Check this box if employer has 50 or more part or fulltime employees
Because of my
Race/Color
National Origin
Disability/Medical Condition
Sex/Gender
Transgender
Sexual Orientation
Age
I was harassed based on my
Race/Color
National Origin
Disability/Medical Condition
Sex/Gender
Transgender
Sexual Orientation
Age
Request for Reasonable Accommodations for Disabilities
Request for a Medical Leave of Absence for Self, Family or Bonding Leave
Retaliation/Whistleblower
Opposing/Reporting Discrimination/Harassment or Retaliation
Because I was Stalked by a Third Party
Because I was a Victim of Sexual Assault by a Third Party
Because I was a Victim of Domestic Abuse by a Third Party
Opposing Employer Policies
Refusal to Participate in Conduct by Employer
Reporting Conduct by Employer
Reporting Fraud, Waste or Abuse
Reporting a Workplace Injury
Relocated to Accept Employment Procured by Employer Misrepresentation
Blackballed by Former Employer from Obtaining New Employment
Complaints About Unfair Wages
Complaints About Fraudulent Accounting Activities by an Employer who is Public Traded
The Harassment was by a
Owner/President/Chief Executive (or Financial) Officer/Executive Director
Supervisor/Manager
Co-Worker
Subordinate Employee
Third Party
I Reported the Unlawful Conduct by My Employer on
Please Detail Specific Facts and/or a Timeline of Discrimination, Harassment and/or Retaliation *
How did you hear about us? *
Dept. of Fair Employment & Housing
Equal Employment Opportunity Commission
CA Employment Lawyers Association
AIDS Legal Referral Panel
Private Attorney
Former Client
State Bar of CA
Union
Google (search engine)
Non-Profit
Other
Submit
