Contact | Law Office of Peggy A. Farrell | Los Angeles CA USA

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CONTACT US

Name

Phone

Email

Pronouns

Employer Name

My Employer is a

Private Entity

Public Entity

Non-Profit

Check this box if employer has 50 or more part or fulltime employees

Last date of incident

Discrimination:

I was

Terminated

Demoted

Suspended

Forced to quit

Denied Reasonable Accommodations for Disability

Denied 12 Weeks of Family Care/Medical Leave

Because of my

Race/Color

National Origin

Disability/Medical Condition

Sex/Gender

Transgender

Sexual Orientation

Age

Harassment:

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

The Harassment was by a

Owner/President/Chief Executive (or Financial) Officer/Executive Director

Supervisor/Manager

Co-Worker

Subordinate Employee

Third Party

Retaliation/Whistleblower:

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

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

Thanks for reaching out! My intake coordinator will email you to follow up.

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