Client Intake Long Form Please fill out this Employment Law questionnaire as much as you can so we can evaluate your case.Your Name* First Last Your Current Address* City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Your Email* Your Phone NumberYour Age*Identify the employer with whom you have a problem.*State the employer's physical address where you worked.*How large is the employer?*1-5 employees6-50 employeesMore than 50 employeesWhen did you start working for the employer?* Date Format: MM slash DD slash YYYY When was your actual last day of work?* Date Format: MM slash DD slash YYYY Describe your job duties.*Describe your compensation structure.*HourlySalaryCommissionsFlat fee per dayPiece rate based on number of units performed.What was your hourly rate during the last pay period?What is your annual gross compensation?Less than $50,000$50,000 - $100,000More than $100,000What was your classification?* I was classified as an employee and employment taxes were deducted from my paycheck. I was classified as an independent contractor and received a 1099 form. I was classified as an employee and independent contractor. Not sure. Are you a member of a union?*Yes, I am a member of a union.No.Not sure.Questions Related to Discrimination or RetaliationDo you believe you were discriminated or retaliated by the employer?*YesNoNot sureIf you believe you were discriminated/retaliated, state the basis of such discrimination/retaliation: Race, ethnicity, or country of origin Complaining about or objecting to unlawful activities Disability Taking sick day to care for myself or family member Age Sex, gender, or sexual orientation Pregnancy other Please describe the "other" basis for discrimination or retaliation:Please describe in details all incidents that you believe were discriminatory/retaliatory:Did you complain about discrimination or retaliation to your superiors?YesNoNot SureCheck all that apply to you: I was terminated or forced to quit as a result of discrimination/retaliation. I was demoted as a result of discrimination/retaliation. My compensation was reduced as a result of discrimination/retaliation. My work hours were reduced as a result of discrimination/retaliation. Other Describe all "other" forms of adverse employment action taken against you as a result of discrimination/retaliation:Questions Related to Unpaid Wages/CompensationDo you believe you are owed any wages/compensation for work performed during the past four years?*YesNoState all facts why you believe you are owed wages/compensation.Do you believe you worked overtime hours for which you were not compensated?YesNoState all facts why you believe you are owed overtime:Do you believe your employer failed to provide you with an opportunity to take a 30-minute "off-duty" meal break within first 5 hours of work?Yes, I believe my employer violated my meal break rights.No, all meal breaks were provided every 5 hours.State all facts why you believe your meal break rights were violated.Do you believe your employer failed to provide you with an opportunity to take a 10-minute "off-duty" rest break every 4 hours of work?Yes, I believe my employer violated my rest break rights.No, I received all rest breaks every 4 hours.State all facts why you believe your rest break rights were violated.Do you believe you had work-related expenses for which you were not reimbursed (e.g. mileage, office supplies, cell phone, etc.)?YesNoDo you believe some of your work hours (or assignments) were excluded from compensation (e.g. travel time, waiting time, pre/post shift inspections, cleaning,etc.)?YesNoState all facts why you believe some of your work hours (or assignments) were not paid by your employer.Do you have an attorney who currently represents you in this matter?*NoYesWho is your attorney?Please add any additional information that may help us to evaluate your case.Consent* I agree to the below terms.By submitting this form you acknowledge and understand that the use of this form in no way creates an attorney-client relationship with Kuchinsky Law Office, PC or Alexei Kuchinsky. An attorney-client relationship will only come into being between you and Kuchinsky Law Office, PC only if you and Kuchinsky Law Office, PC enter into a written fee agreement that is prepared by Kuchinsky Law Office, PC. If you have any questions regarding this disclaimer please contact our office at (628) 200-0902.CommentsThis field is for validation purposes and should be left unchanged.