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Educator / Employment Intake Form

Educator / Employee Name *

First Name

Last Name

Name of Employer *

Position / Title *

Approximate #of Employees (if known)

Years With Employer

Home Address *

Phone

(###)

###

####

Email *

Referral Source *

Adverse Parties *

Witnesses

Are You the Subject of a Current Workplace Investigation? *

Have You Been Subjected to Any of the Following Adverse Employment Actions: *

Placed on Paid Leave?

Placed on Unpaid Leave?

Suspended?

Laid Off?

Nonrenewed?

Terminated?

None of the Above

Not Sure

Date of Adverse Employment Action (if any)

YYYY

Do You (or Did You) Have a Written Employment Contract? *

Have You Been Referred to the Department of Education for Educator Misconduct? *

Have You Been Notified by the Department of Education That an Investigation Has Been Opened (in writing or otherwise)? *

Deadline to Respond or Hearing Date (if any)

Will you be seeking reimbursement of your legal fees through an organization, union, or through insurance? *

Yes, through my teachers union [Note to attorney: AFT = $200/ hour; No flat fee agreements]

Yes, through an organization [Note to attorney: Get details of organization in consult]

No, I will not be seeking reimbursement of fees.

I'm not sure [Note to attorney: Get details of organization in consult]

Brief Description of What Happened

Continue Only for Employment Discrimination/Retaliation Cases: “I am going to ask you some targeted questions that mostly require yes and no answers; when you consult with ATTORNEY, depending upon your answers with me, they will get into further detail with you.”

Do you believe you have been treated differently because of your sex, race, age, disability, religion, age, sexual orientation, ancestry, national origin, familial, or military status?

If YES to the question above, please ID the protected class:

Have you ever reported any harassment or discrimination to your employer?

If YES to making a report of harassment or retaliation:

Check any that apply:

The report was in writing (including by text or email)

The report was made orally

If YES to making a report of harassment or retaliation:, to WHOM did you make the report:

Provide name and/or title

If YES to making a report of harassment or retaliation:, WHEN did you make the report:

Approximate time and/or date

If YES to making a report of harassment or retaliation, have you SINCE suffered different treatment like a pay reduction, demotion, or reduction in job responsibilities?

If YES to making a report of harassment or retaliation, did your employer investigate or address your report?

Yes

Not sure

Check any that apply:

I have filed an EEOC charge (complaint)

I have NOT filed an EEOC charge (complaint)

I have filed an OCRC/MDCR/PHRC charge (complaint) [or other state civil rights commission]

I have NOT filed an OCRC/MDCR/PHRC charge (complaint) [or other state civil rights commission]

If YES to filing a charge (complaint) with either the EEOC or [the state civil rights commission - OCRC/MCRC/PCRC], when did you file (approximately):

If YES to filing a charge (complaint) with either the EEOC or OCRC/MDCR/PHRC, have you met with an investigator?

In regards to FMLA (Family Medical Leave Act), I have:

If YES to requesting, taking or being denied FMLA, have you SINCE suffered different treatment like a pay reduction, demotion, or reduction in job responsibilities?

The form has been submitted. Thank you for reaching out to us for help. We will be in touch to schedule your consultation very soon.

Ohio, Michigan, Pennsylvania , United States 614-745-2001info@education-rights.com

Our Mission: To protect the rights and futures of students and educators.

SERVING STUDENTS AND EDUCATORS STATEWIDE IN OHIO, MICHIGAN and PENNSYLVANIA.

ADVISING STUDENTS NATIONWIDE FOR COLLEGE CODE OF CONDUCT AND TITLE IX CASES.

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Office Hours: Monday - Friday: 8:30am-8:00pm

We value your time. We have a seamless intake process which allows you easily to schedule a consultation with an attorney, typically during your initial communication with our office. In the consultation, we gather facts, ID your goals, determine whether you have a valid legal issue and outline the steps that may be taken to resolve it. We also provide as much certainty about cost as we can from the very beginning. We are focused exclusively on student and educator rights.

k12 STUDENT RIGHTS / SCHOOLHOUSE SEXUAL ASSAULT / SUSPENSION AND EXPULSION / SPECIAL EDUCATION / HIGH SCHOOL ATHLETIC APPEALS / COLLEGE CODE OF CONDUCT / COLLEGE ACADEMIC MISCONDUCT / FRATERNITY AND SORORITY / TITLE IX / EDUCATOR REPRESENTATION / JUVENILE AND TRUANCY

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