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| First Name | : | |
| Last Name | : | |
| Street Address | : | |
| City | : | |
| State/Prov | : | |
| Zip Code | : | |
| Day Time Phone | : | |
| Evening Phone/FAX | : | |
| E-mail Address | : | |
| Date Of Birth | : | |
| Employer Name | : | |
| Have you ever sued anyone before for any reason? | : |
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| If Yes, Who have you sued? | : | |
| If Yes, Why were you suing them? | : | |
| What is your job title? | : | |
| When did you start working for your employer? | : | |
| Are you still employed there? | : |
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| If not, were you fired? | : |
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| If you were fired, when were you fired? | : | |
What has happened that makes you believe you have experienced
discrimination in the workplace? | : | |
Has any manager or employee used any language that
is derogatory to your race, your age, your disability,
your nationality, your gender or your ethnic origins? | : |
|
| If so, please state exactly what was said. | : | |
| What has been said to you? | : | |
| What is the job title of that concerned person | : | |
Have you been touched physically in
any part of your body? | : |
|
| If yes, did you feel this was important to your job to do so? | : |
|
| Have you reported this behavior to anyone at all? | : |
|
| If so, to whom? | : | |
| Have you reported this behavior to anyone in management? | : |
|
| If Yes, to whom? | : | |
| When? | : | |
| Was the report verbally or in writing? | : |
|
| What was management's response? | : | |
When did the acts that you believe were
harassment take place? | : | |
Have you had any emotional or psychological
consequences from the sexual harassment in
the workplace? | : |
|
Have you shared these experiences with a support group,
a doctor, a minister, a spouse, or any other person? | : |
|
| If so, with whom did you share? | : | |
Have you had any physical illness or results from the
sexual harassment? For example, breaking out in hives;
insomnia, (inability to sleep); nausea or vomiting; pregnancy
resulting; headaches (migraine), anxiety attacks, shingles. | : |
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