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If you are interested in submitting your potential case to Mr. Worth to review, please do so by completing the following questionnaire in as much detail as you can.
 
Name:  
 
Address:  
 
City:  
 
State:  
 
Zip Code:  
 
Telephone:  
 
E-mail:  
 
How did you learn about this office?
 
Name of employer:  
 
Address of employer (as shown on paycheck stub or W-2 form)
 
City:  
 
State:  
 
Zip Code:  
 
Telephone:  
 
Address of employer (if different from above)
 
City:  
 
State:  
 
Zip Code:  
 
Telephone:  
 
Current/Last Position:  
 
Number of Employees where you worked  
 
Number of Employees in whole company:  
 
Are you still working for the employer?  
 
If "Yes", what was the reason the employer gave you (even if you do not believe it is true)?  
 
If you do not believe the reason the employer gave you, what do you think the real reason was?  
 
Did you quit?  
 
If "Yes", why?  
 
Your age at the time of the employer's wrongful act(s)  
 
Are you a minority?  
 
Were you terminated?  
 
Were you disabled due to a work related injury at the time of termination  
 
If yes, please explain  
 
Were you pregnant a the time of your termination?  
 
Were you physically or mentally disabled at the time of your employer's wrongful act(s)?  
 
If yes, please explain  
 
Were you sexually harassed?  
 
If yes, please explain  
 
 
Do you get paycheck deduction statements (pay stubs) with your check?  
 
What was your rate of pay (per hour if you were paid hourly, salary rate if paid salary)?  
 
Please give a brief description of your most time-consuming duties in a typical day, week, or month.  
 
How many hours did you work per week on average? (It's OK if you do not know precisely, averages are fine. Like in Olympics scoring, disregard the exceptionally high and exceptionally low instances, and focus on what is typical or average, such as "5 hours a week", "2 hours per day", etc.)  
 
Do you believe you are entitled to an unpaid bonus?  
 
If "Yes", please describe how you believe you are entitled to an unpaid bonus.  
 
Do you believe you are entitled to unpaid commissions?  
 
If "Yes", please describe how you believe you are entitled to unpaid commissions.  
 
Do you ever miss your meal break (defined as at least 30 minutes free from all interruptions, regardless of whether you ate or not)?  
 
If "Yes", how often did you miss a meal break? (It's OK if you do not know precisely, averages are fine.)  
 
Do you ever miss one or both of your rest periods (defined as at 10 minutes free from all interruptions, regardless of whether you ate or not)?  
 
If "Yes", how many days did you miss one or more rest periods? (It's OK if you do not know precisely, averages are fine.)  
 
Did you ever work off the clock?  
 
If "Yes", how many hours off the clock did you work? (It's OK to state an average, such as "three hours per week", "one half day every other Saturday", etc.)  
 
If "Yes", why did you work off the clock/not record your hours worked?  
 
How long have you worked for the employer?  
 
Is there anything else that you think the lawyer needs to know to understand your case?  
 
Personal Injury Section
 
Who was at fault?  
 
What are the injuries known at the present time?  
 
If you were driving, was your car insured with liability insurance at the time of the accident?  
 
Were you a passenger of another person's car at the time of the accident?  
 
If yes, please explain  
 
Did you need immediate medical attention for any injuries you or someone close to you suffered?  
 
If yes, please explain  
 
Do you need a doctor for treatment?  
 
DO you have information on the other, responsible driver(s)?  
 
If yes, please explain  
 
Was there a police report made?  
 
If yes, please explain  
 
Any other special facts or information to provide?  
 
If yes, please explain  
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