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Employment Questionnaire
For California And Hawaii Only
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You may fill in the
following information and either email it to us by pressing the
SUBMIT button at the bottom or printing the form and fax it to 1-888-485-1200 |
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Name:
Address:
City and State:
Phone: Email:
Age:
Sex: Job Title:
Last Monthly pay level: |
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EMPLOYMENT
DISCRIMINATION OR OTHER PROBLEMS: |
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Name of
employer:
Over 15 employees? YES: NO: Your
date of hire or application (if not hired): |
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Adverse act
against you:
Termination: YES: NO:
Harassment: YES: NO:
Denied a Promotion: YES: NO:
Denied being Hired: YES: NO:
Retaliation/Termination - Whistle blowing, complaining of discrimination
Other: Denial of Services or access
due to disability:
Other:
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Name and
position of person committing or informing you of adverse act:
Dates of Adverse Acts, starting with most recent one:
Reasons given for adverse acts:
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Were the Acts
done due to discrimination based upon your:
Age: YES: NO:
Sex: YES: NO:
Race: YES: NO:
National Origin: YES: NO:
Disability Status: YES: NO: Other
(describe):
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If Sexual
Harassment, did it involve unwelcome touching: YES: NO:
When did your employer know about it:
What remedial action was taken by employer:
If Disability, what is your disability:
When did your employer or business know about your disability condition:
What service or access was denied or limited due to your disability status:
Were any efforts at reasonable accommodation attempted: YES: NO: If reasonable accommodation was attempted, explain:
If any, what discriminatory statements were made by
supervisors
(examples: "racial" or"sexual" slurs, "woman or older person
can't
do this job," "need younger image"):
Who witnessed these statements:
Have you filed a complaint with the EEOC or other agency? YES:
NO:
If a complaint was filed, with whom and when?
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Did you sign a waiver,
release, or arbitration agreement:
(check your application and employee manual) Amount
of financial harm to date:
Salary loss: Medical
Costs: Other:
Have you or your family suffered other harm from these
incidents, describe:
Any other specific questions?
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If your question
involves a document/letter about your work situation or
termination/demotion, it would help if you faxed or mailed it to us.
If you do so check here: |
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