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Employment Practice Law Case Questionnaire

General Information

*Submitter's Name:

*Court:

State

*Outcome:

Federal

Plaintiff Verdict

Defense Verdict

Settlement

*Case Caption:

Explanation of Outcome:

*State:	*County:	Federal District:
*Court Level:	Docket#:
Judge:
Date of: (MM/DD/YY)
Incident:	Filing:	*Date of Outcome:

Appeal Information

Appeal Filed?
(check if yes)

Appellate Docket#:

Date:

Appeal Filed by :

Plaintiff

Defense

Name of Party:

Plaintiff Award Breakdown (plaintiff verdicts and settlements must have $ amount)

Reinstatement as part of plaintiff award (check if yes)

*Total Award: (should equal sum of fields below)

	Back Pay:	$		Compensatory Other:	$
	Front Pay:	$		Punitive:	$
	Attorney's fees:	$		Other Noncompensatory:	$
	Interest:	$
Amount of Award After Statutory Cap/Limit:			$

Acts and Statutes (check all that apply)

Federal:

ADA - Americans with Disabilities Act

Title VII - National origin discrimination

ADEA - Age Discrimination in Employment Act

Title VII - Pregnancy/childbirth discrimination

EPA - Equal Pay Act

Title VII - Race/color discrimination

FMLA - Family Medical Leave Act

Title VII - Religion discrimination

Rehabilitation Act 1973

Title VII - Retaliation

Title VII - Sex discrimination

Other:

State:
State Act:		or Statute:

Adverse Employment Actions (check all that apply)
	Closer supervision and/or scrutiny	Harassment	Negative job reference
	Constructive Discharge	Hostile work environment	Pay increase denial
	Demotion	Isolation or ostracization	Reassignment or transfer
	Denial of tenure	Lay-off	Reduction in pay
	Failure to accommodate	Loss of benefits	Reprimands
	Failure to grant leave	Loss of pay	Restrictions
	Failure to hire or rehire	Loss Seniority	Suspension
	Failure to promote	Negative evaluation	Termination
			Other

Contentions
Final Demand:	$	Final Offer:	$
Future Wage Loss Claim By Plaintiff Economist:	$	Future Wage Loss Claim By Defense Economist:	$
Back Pay Claimed:	$	Past Medical Expense Claimed:	$
Front Pay Claimed:	$	Future Medical Expense Claimed:	$
*Plaintiff Contentions:

*Defense Contentions:

	Material Facts

Plaintiff Information

Defendant Information

	*Sex	Age	Race	Occupation
Pltf 1
Pltf 2
Pltf 3
Pltf 4

	*Sex	Age	Race	Business/Industry Type
Def 1
Def 2
Def 3
Def 4

Def. #:

Insurance:

Policy Limits:

	*Attorney Information
	*Plaintiff Attorney(s) (name, firm, address, phone & fax):

	*Defense Attorney(s) (name, firm, address, phone & fax):

	Witness Information
	Plaintiff Expert Witness(s) (name, expertise, address, phone & fax):

	Defense Expert Witness(s) (name, expertise, address, phone & fax):

* = Required Fields

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