Termination or Still Employed Evaluation ; 1 Your Contact Information2 Employer & Work Details3 Statuses & Legal Actions4 Extended Details 1. Your Contact InformationName* First Last Your Phone*Your Email* 2. Employer & Work DetailsName of Company/Employer*Address of Work Location*Job Title*Date Started Working* Date Format: MM slash DD slash YYYY Date Last Worked* Date Format: MM slash DD slash YYYY Date Last Paid* Date Format: MM slash DD slash YYYY Number of Days Worked Per Week1234567Hours Worked Per DayPaid By:HourSalaryOtherHow Much Do You Get PaidDoes Company have more than 15 employees?*YesNoDoes Company have more than 50 employees?*YesNoDo you work for the government?*YesNoAre you part of a union?*YesNoDo you have an Employment Contract that Guarantees employment for 1 or more years?*YesNoDo you have contact information for Human Resource department or company management?Name of Supervisor 3. Statuses and Legal ActionsComplaintsHave you filed a Complaint with the Company/Employer internally?*YesNoLawsuitsHave you filed a lawsuit?*YesNoDates & DeadlinesDo you have any deadlines?*YesNoDate of Deadline Date Format: MM slash DD slash YYYY BankruptcyHave you or will you file for Bankruptcy?*YesNoDate of Bankruptcy Date Format: MM slash DD slash YYYY UnemploymentHave you filed for Unemployment Benefits?*YesNoDate Date Format: MM slash DD slash YYYY What is the Unemployment Status?DisabilityHave you filed for disability benefits?*YesNoDate Date Format: MM slash DD slash YYYY Retirement & PensionDo you have a retirement date or pension?*YesNoDate Date Format: MM slash DD slash YYYY Extended DetailsAre your issues related to any of the following? Pregnancy Discrimination or Harassment Sex Harassment Medical Accommodations or Medical Leave The Family and Medical Leave Act Complained about illegal activity or refused to perform illegal activity at work that can lead to government penalty, loss of licenses, etc. Age Discrimination Disability Discrimination Medical Restrictions Medical Accommodations National Origin Discrimination – Treated unfavorable - because they are from a particular country or part of the world, because of ethnicity or accent, or because they appear to be of a certain ethnic background (even if they are not). Religion Discrimination Sex or Gender Discrimination Unequal Pay due to discrimination Injury at work or because filed for worker’s compensation application or request Race or Color Discrimination Who hired you?Who terminated you if applicable and how?Who are you having issues with at work?What was the reason given for your termination or issues at work?What do you think the real reason is for your termination or issues at work?Who did you complain to at work?What exactly did you say?What was the response from the company?Did you complain about discrimination at work? What dates? Written proof?Name of Employees treated better than you and their job title:Action taken against you that was discriminatory and the date it happened?Please provide Examples and Dates - List up to 3 This iframe contains the logic required to handle Ajax powered Gravity Forms.