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Case Evaluation

This questionnaire helps an attorney get a full picture of your situation before responding. It takes a few minutes — answer what you can, and skip anything you're not sure about.

On your phone? You can use your keyboard's microphone/dictation button to speak your answers into the longer text fields instead of typing.

Contact Information Full name Email Phone

Employment Details Employer name Your job title Supervisor's name Are you still employed there?

Yes No

Employment start date Employment end date (if applicable) City / state where you worked Approximate number of employees at the company

Nature of Your Concern What best describes your situation? (select all that apply)

Discrimination Harassment / hostile work environment Retaliation Wrongful termination Wage & hour issue Whistleblower retaliation FMLA / medical leave Denied accommodation Non-compete / restrictive covenant Severance agreement Other

If discrimination or harassment applies, on what basis? (optional)

Timeline When did the issue first begin? Date of the most recent incident Date of termination (if applicable)

What Happened Describe what happened, in your own words Who was involved? (names and titles) Were there any witnesses?

Prior Steps Taken Have you reported this to HR or a manager?

Yes No

Have you filed a charge with the EEOC, DOL, or a state agency?

Yes No

Agency case number, if known Are you currently working with another attorney?

Yes No

Documentation What documentation do you have? (select all that apply)

Emails or texts Performance reviews Pay stubs Termination letter Employee handbook Witness statements EEOC charge Employer position statement Complaint Other

What You're Looking For What outcome are you hoping for?

Attach documents (optional)

The McCabe Law Firm
Employment & Whistleblower Law
mccabe-lawfirm.com