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Employer Name Job Title Employer Phone Number Employer Address Current Salary

Describe what happened at your place of employment that caused you to seek legal action? When did the events above take place? Do you believe that your treatment at work was motivated by Discrimination? If so, on what basis? (race, sex, gender, age, national origin, sexual orientation, religion, disability, marital status, pregnancy, gender, sexual harassment?) Were comments made about your protected category? If so, describe with dates, name of person who made the comments Were you treated differently than people of different protected category than you (Ex; different race, different religion, etc.)? Describe Do you believe that you were retaliated against for complaining about discrimination or for complaining about some illegal activity at the workplace? If so, please provide details (exactly, what did you complain about?): Did you complain in writing or verbally? (Please provide dates and method of communication) Who did you complain to (i.e., manager, president, director, supervisor, etc.)? What was the response of the employer when you complained (i.e., investigated, did nothing, punished you, etc.)? Do you have any witnesses or documents to help prove your claims? If so, describe

Please describe the nature of the disability? Did you inform the employer about your disability? Did you request reasonable accommodations? Did the Employer provide reasonable accommodations? If so, describe: Did you Take a Medical Leave? If so, what dates?