Sexual Harassment Inquiry Form - The Burkhalter Law Firm

Todays Date *

Name *

First

Last

Address (Street, City, State, & Zip Code) *

Email *

Contact Phone Number *

When is the best time to contact you, and how would you prefer we contact you?

Name of employer (If you prefer, this information can be withheld at this time).

Date Of Hire.

Approximate number of employees working for this employer.

Do you have any witnesses who will testify?

Name and title of the sexual harasser.

Was the harasser your supervisor? Explain.

Please describe the nature of the harassment.

How have you been damaged by the harassment? Please describe the injuries.

Did you complain about the sexual harassment? If so, to whom, when, and explain what happened.

Were you retaliated against for complaining.

Were you terminated? .Yes or No

If so, what was the date of termination

Reason (or reasons) why you feel you were terminated

Last job title (or position)

Union member?.Yes or No

How did you hear about us?

Phone