Card Version Employment Survey 12.25

1

Name* This field is required.

First Name

Last Name

2

What is the name of your employer?* This field is required.

3

How many employees does your employer have?

4

How long were you working at this job? (For example, "From August 2, 2012 - November 30, 2020."* This field is required.

5

Which of the following best describes your issue? (select all that apply)* This field is required.

I am not being paid all my wages (e.g., overtime, meal/lunch period violations; rest break violations; not being reimbursed; paid below minimum wage; etc.)

I am being harassed/discriminated against

I am being retaliated against

I was terminated

I was laid off

I was injured at work

My employer is engaging in unsafe and/or unlawful activities

Other

6

Briefly describe what happened. (The more information you provide, the better the attorney can evaluate your case.)* This field is required.

7

What is your email address?* This field is required.

8

What is the best phone number to reach you at?* This field is required.