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My Employer is a... (required)
Private EntityPublic EntityNon-Profit

My Employer Has Fifty (50) or More Part or Full Time Employees (required)
YESNO

If you felt you were discriminated against please answer the questions below:
I was:
TerminatedDemotedSuspendedForced To QuitDenied Reasonable Accommodation for DisabilityDenied 12 Weeks of Family Care/Medical Leave

I was discriminated because:
Denied 12 Weeks of Family Care/Medical LeaveDisability/Medical ConditionRace/ColorDisability/Medical Condition (including physical/mental, HIV/AIDS and Hepatitis CNational Origin (including language)Sex/Gender (including gender expression and gender identity)Transgender (including transition)Sex/Gender (including gender expression and gender identity)Sexual Orientation (including perception)AgeOther

Last Date of Incident:

If you felt that you were harassed please answer the questions below:
I was harassed based on my:
Race/ColorNational Origin (including language)Sex/Gender (including gender expression and gender identity)Transgender (including transition)Sexual Orientation (including perception)AgeRequest for Reasonable Accommodations for Disabilities (including pregnancy)Request for a Medical Leave of Absence for Self, Family or Bonding Leave (including paternity leave)

Last Date of Incident:

The harassment was by a:
Owner/President/Chief Executive (or Financial) Officer/Executive DirectorSupervisor/ManagerCo-WorkerSubordinate EmployeeThird Party

If you felt you were the victim of retaliation for reporting an incident or whistle blowing please select any of the actions below that apply to you:

Opposing/Reporting Discrimination/Harassment or RetaliationBecause I was Stalked by a Third PartyBecause I was a Victim of Sexual Assault by a Third PartyBecause I was a Victim of Domestic Abuse by a Third PartyOpposing Employer Policies that Prevent Employees from Reporting Conduct by the Employer Reasonably Believed to be in Violation of State or Federal Law, Rule or Regulation.Refusal to Participate in Conduct by Employer Reasonably Believed to be in Violation of State or Federal Law, Rule or RegulationReporting Conduct by Employer Reasonably Believed to be in Violation of State or Federal Law, Rule or RegulationReporting Fraud, Waste or Abuse by a Public EntityReporting a Workplace InjuryRelocated to Accept Employment Procured by Employer MisrepresentationBlackballed by Former Employer from Obtaining New EmploymentComplaints About Unfair WagesComplaints 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, Harrassment and Retaliation (required):

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Search EngineAdvertisingDepartment of Fair Employment & HousingEqual Employment Opportunity CommissionCalifornia Employment Lawyers AssociationPrivate AttorneyFormer ClientState Bar of CaliforniaUnionNon-Profit

By submitting this form, you understand and agree that we have not agreed to represent you in any matter and that no attorney-client relationship has been formed.