Stephen P. Horner

Practice in the area of employment & Labor Law

Phone: (203) 245-0134

Three Longview Terrace, Madison, CT 06443

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Free Confidential Case Evaluation Questionnaire

If you would like a free initial review of your employment discharge or employment claim, please fully complete the following confidential questionnaire. This takes about twenty minutes. After Attorney Horner reviews your responses, you will be advised as to whether your employment claim justifies further legal review. He will respond to your questionnaire within one business day.

Severance agreements are not covered by this free review of your employment claims.

If you prefer, he can send the questionnaire to you by mail.


Instructions

All responses to the following questions will be kept confidential.

Please complete ALL parts of the questionnaire that pertain to your situation.

You should complete the questionnaire as soon as possible because there may be time limitations to your claims.

You may approximate dates, ages, or amounts in your responses; we can obtain the exact information later; please use "approx" to indicate approximations.

Thank you.


1.  Your Background Information
Name:
Address:
City, State, Zip:
Telephone Numbers

    Business:

    Home:

    Confidential Fax:
Confidential Email:
 
Sex: Male      Female
Race:
Date of Birth:
Social Security Number:   optional
Education: High School
College Degree
Graduate Degree

Are you currently employed?      Yes      No
If so, name and address of current employer:

Company:

Address:

City, State, Zip:
2.  Company Information

( The following questions relate only to employment where you believe you were wrongfully treated or illegally discharged. )

I believe I may have an employment claim against:

Company:

Address:

City, State, Zip:
How many employees does the company have?
  Less than 3       3 - 15       15 - 20        Over 20

Type of business:
Financial condition of company ( if known )?
  Poor       Fair       Good        Excellent
3.  Employment with Company Against Whom You May Have a Claim
Initial job with this employer:
Job Title
Annual Salary
Date of Hire
Most recent job with this employer:
Job Title
Annual Salary
Date Began
During the last five years of your employment did you receive any:

Salary increases?

  Yes       No

Bonuses?

  Yes       No
Give the name and job title of your current supervisor and the length of time you worked under him or her:

Name:

Job Title:

Length of Time:
Have you had problems with this supervisor?       Yes       No
Your job location (town and state):   
Did you supervise employees?       Yes       No

If yes, how many?     

Does the employer give written performance evaluations?     Yes    No
Do you have copies of your evaluations?     Yes    No
Was your performance generally:
 Excellent       Good       Average       Below Average
Have you ever had any performance problems prior to being discharged?

 Yes       No

If so, state when the problems occurred and explain:

 
Did you receive oral or written warnings or were you placed on probation?

 Yes       No

If yes, when?     

When did you first become aware that your employer was dissatisfied with you?

When were you first told that you were going to be discharged?     

What was said to you about why you were being discharged?

When was your last day of employment?     

Have you signed a resignation letter?     

 Yes       No

or a release of liability form?

  Yes       No
Do you believe the reason given for the action taken against you was false?

 Yes       No

If yes, explain:

Did you frequently work over 40 hours per week?       Yes       No

If yes, were you paid overtime?       Yes       No

Have you been replaced?       Yes       No       I don't know

What percent of your duties is he/she now doing?      %

Please provide the following information about your replacement (if known):

Sex:

 Male      Female

Race:

Age:

New Hire?

  Yes       No       I don't know
4.  Please Explain What Your Employment Claims Are

5.  Employment Status with Company Against Whom You May Have a Claim
Did you have a written employment contract?

 Yes       No       I don't know

Were you a Union member?       Yes       No

Did you file a grievance?        Yes       No

Did anyone in management give you any assurances of job security?

 Yes       No       I don't know
Did the company have an employee handbook or personnel manual?

 Yes       No       I don't know
6.  Discrimination
Do you feel that you have been discriminated against by the company?

 Yes       No       I don't know
Do you feel that the company treated you differently because of your:

Age

Sexual Preference National Origin

Sex

Sex Harassment Retaliation

Race

Pregnancy Disability/Handicap

Religion

Vietnam Veteran
Have you ever taken a disability leave of absence or received disability payments?

 Yes       No
Were any discriminatory comments made?

 Yes       No       I don't know

If yes, what were they?

Were other employees discharged at the same time as you?

 Yes       No       I don't know

If yes, how many?  

Are there any witnesses (current or former employees; customers, etc.) who could (or might) support your claims?

 Yes       No       I don't know
 
7.  Miscellaneous
 
Do you feel that you were discharged (or forced to resign) because you:

refused to perform an illegal, unethical or improper act?

 Yes       No       I don't know

filed a Worker's Compensation claim?

 Yes       No       I don't know

were close to receiving substantial commissions?

 Yes       No       I don't know

had "blown the whistle" on illegal company activities?

 Yes       No       I don't know

had opposed discriminatory acts?

 Yes       No       I don't know

had exercised your free speech rights?

 Yes       No       I don't know

had complained about safety violations?

 Yes       No       I don't know

had engaged in union organizing activities?

 Yes       No       I don't know

rebuffed sexual advances and/or were sexually harassed?

 Yes       No       I don't know

had a personality conflict with your supervisor?

 Yes       No       I don't know
 
8.  Post-Employment
 
Were you paid all the salary, bonuses, vacation pay and commissions due to you?

 Yes       No
Were you informed of your COBRA rights (option to continue medical insurance)?

 Yes       No
Have you been disabled (or received Social Security disability payments) for any time period during the last five years?

 Yes       No
Have you obtained new employment?       Yes       No

Start Date: 

If so, is the salary substantially lower?        Yes       No

If so, are the benefits substantially lower?       Yes       No
Have you filed a discrimination charge with The Equal Employment Opportunities Commission or the Connecticut Commission on Human Rights and Opportunities?

 Yes       No
If your employment was covered by a collective bargaining agreement, did you file a grievance or ask your union to file a grievance on your behalf?

 Yes       No
Did you receive an offer of severance pay?       Yes       No

If so, how much?
Around the time of your termination, were any other employees terminated?

 Yes       No

If so, how many?

What do you believe motivated your employer to treat you this way?

How were you referred to this office?

 Speech

 Yellow Pages  Newspaper Column  Attorney Referral  Client Referral

 Internet

  Other
How did you find our site?

Referred by:

Name:

I understand that the filing deadline for claiming discrimination under Connecticut state law is 180 days from when I was first informed of the discriminatory action (i.e., when informed of discharge, lost promotion, etc.) and 300 days (from that same starting point) under Federal law. Some other deadlines may be much shorter (union grievances) and some may be much longer (torts, wrongful discharge and breach of contract).

I understand that only this discharge questionnaire will be reviewed without any expense to me and that I will then be advised as to whether my circumstances justify further review or not.

Submitting this form confirms my belief that all of my answers provided on this questionnaire are true and accurate to the best of my knowledge.
It may take some time to submit this form. Please click the submit button only once.

Areas of Practice

  • Employment agreements
  • Severance agreements
  • Restrictive covenant agreements
  • Evaluation of legal claims
  • Mediation of disputes
  • CHRO/EEOC claims
  • Wage and Hour claims

Rated a “Super Attorney” by Law and Politics for the last four years.