SLC Legal | Employment Intake

Full name Phone Email Employer name Job title Employment start date Are you still employed? Hourly rate or salary Work schedule Job duties Union or non-union? Government or private employer? Approximate number of employees Employer phone number Employer address

1. Which issue fits best?

Pick every category that applies.

Retaliation

Discrimination

Harassment

Wrongful termination

Accommodation / interactive process

Leave / CFRA / FMLA / Paid Family Leave

Whistleblower / 1102.5

Wage retaliation / 98.6

Wages / overtime / breaks / statements / PAGA

Other employment issue

2. If this involved harassment, discrimination, or retaliation, what was it based on?

Select every basis that applies.

Race

Color

Ancestry

National origin

Religion / creed

Sex / gender

Gender identity / expression

Sexual orientation

Age 40+

Marital status

Medical condition

Physical disability

Mental disability

Pregnancy / childbirth / breastfeeding

Genetic information

Military / veteran status

Other protected basis

Not sure

If you selected a protected basis, explain briefly

3. Retaliation

What did you do before things changed?

Complained to HR / management

Reported discrimination / harassment

Requested leave

Requested accommodation

Complained about pay / breaks / overtime

Reported unlawful conduct

Refused unlawful conduct

Other protected activity

What happened after that?

I reported it

I did not report it

Not sure

If you reported it, to whom and when?

4. Discrimination

What specific action happened to you?

Fired / forced out

Demoted

Hours / pay cut

Denied promotion

Write-ups / discipline

Bad assignment / transfer

Not hired / not selected

Benefits / leave denied

Other adverse action

What happened, how did it happen, how many times, and by whom? What was the job title of the person or people involved?

I reported it

I did not report it

Not sure

If you reported it, to whom and when?

5. Harassment

What kind of harassment happened?

Verbal comments

Texts / messages / emails

Touching / physical conduct

Jokes / slurs / mocking

Images / gestures

Other conduct

What happened, how often did it happen, who did it, and what was their job title? Did it affect your work, schedule, health, or willingness to come to work?

I reported it

I did not report it

Not sure

If you reported it, to whom and when?

There was a prior relationship

No prior relationship

Not applicable

If there was a prior relationship, when did it end and how was that communicated?

6. Accommodation / interactive process

Use this section for disability, medical condition, pregnancy, or work restrictions.

Disability / medical condition

Pregnancy-related need

Work restriction / light duty

What was the condition or limitation?

I had a doctor’s note

No doctor’s note

Not sure

What accommodation did you request? When and how did you tell the employer?

They discussed options with me

They did not discuss options

Not sure

What happened after the request?

7. Leave / CFRA / FMLA / Paid Family Leave

This section helps screen leave-related claims and retaliation after leave requests or leave use.

My own health condition

Family member’s condition

Baby bonding / parental leave

Approximate leave start Approximate leave end How long had you worked there before leave? Hours worked in the 12 months before leave How was leave requested? What happened after the leave request or after leave was taken?

8. Whistleblower / 1102.5

Use this if you reported unlawful conduct, safety issues, fraud, patient care problems, or other legal violations.

What did you report? To whom did you report it, and when? What happened after the report?

9. Wage retaliation / 98.6

Use this if you complained about pay, breaks, overtime, or wage statements and then the employer turned against you.

Unpaid overtime

Missed meal or rest breaks

Unpaid wages / final pay

Wage statement problems

Other wage issue

What did you complain about, to whom, and when? What happened after the complaint?

10. Wages / overtime / breaks / statements / PAGA

Pick the wage issues that apply and then explain briefly.

Unpaid overtime

Off-the-clock work

Meal break violations

Rest break violations

Wage statement violations

Final pay / unpaid wages

One in seven day-of-rest

Coworkers had same problem

Briefly explain the wage problem

Witnesses who can support your account Records and documents Your story

This intake is designed to screen the facts cleanly and quickly so the right claim signals do not get lost.

Tell us your story, from start to finish.

This intake is built to narrow the issue quickly.

1. Which issue fits best?

2. If this involved harassment, discrimination, or retaliation, what was it based on?

3. Retaliation

4. Discrimination

5. Harassment

6. Accommodation / interactive process

7. Leave / CFRA / FMLA / Paid Family Leave

8. Whistleblower / 1102.5

9. Wage retaliation / 98.6

10. Wages / overtime / breaks / statements / PAGA