Winston Salem: 336-724-2828 / Charlotte: 704-707-3705

Employment Law Questionnaire

Please complete all areas.

***NOTE: Our policy is to respond to your inquiry within 48 hours. If you believe that a quicker response is necessary (i.e., you have an urgent meeting scheduled with your manager or a hearing, etc., prior to that time) please explain your need and we will immediately let you know if we can help you sooner.





Date of Birth*

Employer Name*

Employer Address*

Does your employer employ at least 15 employees?*

Does your employer employ at least 20 employees?*

Does your employer employ at least 50 employees?*

Job Title*

Job Description*

Date of Hire*

What was rate of pay?*

0 of 100 max characters

Date of Adverse Employment Action*

Adverse Employment Action Taken*

Reason given by Employer for Adverse Action*

Reasons you feel were behind the Adverse Action*

Because of my age

Because of my gender

Because of my pregnancy

Because of my disability

Because of my religion

Because of my nationality

Because of my race

Because my doctor won't let me return to work at the end of my leave period

Because I filed for Workers' Compensation

Because I was falsely accused of wrongdoing

Because I filed a complaint

Because of a personal disagreement I had with my supervisor

Other, please describe below

Please explain/describe the circumstances for any of the above reasons that apply to your situation

Have you filed a complaint with any agency?*

If 'Yes', which Agency?

Have you received a ruling or decision or notice of your right to sue?*

If 'Yes', please state the ruling or decision, and the date of the decision or notice.

What losses have you suffered?*

0 of 700 max characters

(Lost wages- how much; lost bonuses/commissions;lost benefits; other)

Do you have an employment contract?*

If 'Yes', please provide a copy of your contract.

Are you represented by a union?*

Have you applied for unemployment benefits?*

If 'Yes', were you awarded benefits?

If 'No', did you appeal?

If you appealed, what is the status of your appeal?

Have you been offered a Severange Agreement?*

Have you obtained other employment?*

If 'Yes', where?

If you have obtained other employment, what is your new Job Title?

If you have obtained other employment, what is your new rate of pay?

How did you learn about ELLIOT MORGAN PARSONAGE, PLLC?