Employment Intake Rio Law Group

1

What's your name?

2

Briefly describe your employment problem

3

Type of employment case(based on the information provided)

Wage and Hour Violations (no rest breaks, no meal breaks, no minimum wage, no overtime, etc.)

Discrimination (race, age, gender, religion, disability, medical condition, pregnancy, sexual orientation)

Sexual Harassment

Retaliation (for getting injured at work, for filing worker's comp, reporting an unsafe workplace, etc.)

Worker's Compensation (injured at work)

Other

4

If the injury was an on the job injury, do you have a Workers Compensation Attorney?

No

Yes

Not a work injury

5

Are you getting your rest breaks?(10 min rest break for every three hours worked)

Yes

No

Sometimes

6

Are you getting your meal breaks?(30 min meal break for every five hours worked)

Yes

No

Sometimes

7

Are you getting paid minimum wage?($12/hour for companies with 25 or less employees. $13/hour for companies with more than 25 employees)

YESNO

8

Are you getting paid overtime?(working more than 8 hours in one day or 40 hours in one week should be paid overtime rate of 1.5x regular rate)

Yes

No

Sometimes

9

How many times has the violation happened?

1-10 times

11-50 times

50 + times

N/A

10

Did you report these problems to the company/supervisor in writing, verbally, both, or neither?

reported verbally

reported in writing

both, writing and verbally

neither

Other

11

Can you provide documentation of the writing?

Yes

No

13

When was the last time the discrimination happened?i.e., last adverse employment action

14

Did you report these problems to the company/supervisor in writing, verbally, both, or neither?

reported verbally

reported in writing

both, writing and verbally

neither

Other

15

Can you provide documentation of the writing?

Yes

No

16

What was your date of hire?

17

Is the offender another employee or someone above you (e.g., owner, manager, supervisor)?

Another employee

Someone above you

Other

18

Did you tell or communicate to the harasser to stop?

YESNO

19

Do you have any other evidence of the harassment? i.e. witnesses?

20

Did you report these problems to the company/supervisor in writing, verbally, both, or neither?

reported verbally

reported in writing

both, writing and verbally

neither

Other

21

Can you provide documentation of the writing?

Yes

No

22

What evidence do you have of the harassment? (E.g., text messages, emails, photos, written document, etc.)

23

When was the FIRST time the harassment happened? Provide month and year

24

When was the LAST time the harassment happened? Provide month and year

25

Why did the employer retaliate against you?(if other, please provide a brief description)

Getting injured at work

Filing a work comp claim with the employer

You reported them to a government agency for breaking the law or unsafe workplace, i.e., Whistleblower

For complaining to the employer about the employer breaking the law or unsafe workplace, i.e., Whistleblower

Other

26

Briefly explain how they retaliated against you.(keep this brief)

27

When did the injury happen?(approximate date)

28

Did you report the unsafe workplace in writing?

YESNO

29

Brief explanation of how & why employer retaliated against you?

30

When was the last time the retaliation happened?(approximate date)

31

Do you have a copy of the written complaint?

YESNO

32

What is the injury?

33

Did the injury happen less than a year ago?

YESNO

34

Are you getting your 30 min meal and 10 min rest breaks?(if they respond no please go back and add wage and hour and ask those questions)

YESNO

35

If it happened more than a year ago - Did you file a worker's compensation claim within one year of the injury?

YESNO

36

Was there an accommodation required by your doctor?

Yes

No

37

What was the medical limitation?

39

Did the employer accommodate these restrictions?

Yes

No

40

If not, did you make complaints regarding the lack of accommodation?

Yes

No

41

Written or verbal complaints?

Written

Verbal

Both

42

Do you use your personal cell phone, computer, or vehicle for work?

YESNO

43

Do you receive reimbursements?

YESNO

44

Which have you not received reimbursements for?

Cell Phone

Car

Personal Computer

45

How many locations does the company/employer have?

46

How many years has the company been in business for?

47

How many employees does the company/employer have?

48

How do you get paid?

Hourly

Salary

Other

49

How much are/were you getting paid?

50

What is your date of hire?month and year

52

Did you find a job since you were terminated?

Yes

No

53

What was the date you started this new job?

54

What city do you live in?

55

What city and county is company located?

56

What is the name of the company or employer?

57

Phone Number* This field is required.

58

Email Address* This field is required.

59

Reply to email (internal use only)

example@example.com

60

Is this happening to other employees?

No

Yes

Unknown

61

Do you have their contact information?

Yes

No

Does not want to provide at this time

62

Please provide their contact information and let them know we will be contacting them.Name, phone number, email

63

Name of person who referred if attorney, employee, client, friend/family