Employment Client Intake
Intake Questionnaire for Prospective Clients

1. Preliminary Directions: Please note that all information is attorney client privileged. Our office will also have to do a conflict check prior to reading the responses to determine whether or not our office is not in conflict with current or former clients. These cases are very fact intensive so the more information and detail the better. This process will help us better assess your case. A personal narrative that is very detailed can also help be used as evidence down the road, so the more that is done now the less work the client will need to do in the future.

The case can only be proved with evidence and a lot of it are personal accounts. You make write attach the statement in a separate document or e-mail. We understand that some of these cases can be emotionally tasking dealing with the details and reliving them. With that, please fill out as much as you can understanding your personal limits. One reason why attorneys are so important in society is that it gives an individual the ability to cast their societal burdens and emotions to someone else to handle. This can relieve a lot of stress in handling the matter on their own which makes the concept of an attorney even more so valuable. At that point, the client only has the duty to accept or reject offers and testify if needs be. Please send all attachments, documents or statements to brianj@bjacksonlaw.com or through fax at (801)-534-1948. You may also share documents through Google Drive or mail them to the following address:

Brian K. Jackson, LLC
341 S. Main St. Suite 500
Salt Lake City, UT 84111

2. Disclaimer: Please note that filling out this form does not create an attorney-client relationship. The client and the attorney first must agree to the terms of the relationship prior to taking on the case. There may be several reasons why the firm may or may not ultimately take on the case including but not limited to the strength and weaknesses of the case, whether or not there is an actual legal claim, the amount that can be recovered and the amount of time needed, whether or not this case is in the right jurisdiction, if the statute of limitations has already ran, if there is a conflict with the client or whom the action is against or other factors and considerations based on internal polices of the firm and under the laws of ethics.

The firm's fee system varies depending on the case. In some cases, the firm will charge an hourly rate for work done which is usually $250 an hour. A personal consult is also the same rate. The hourly rate is charged in increments of .6 of a minute. Other cases, the firm may take on at a contingency rate of 30% of any funds awarded to the client. There still may be some upfront costs and the client would still have to pay for the court fees and litigation costs associated with the case such as filing fees, deposition fees, expert witness fees ect, there also may be an upfront cost to the firm to commence the litigation and thereafter the rest of the case would be based on contingency.

3. Awards in Discrimination cases: Clients should take into consideration the award amounts for discrimination and wrongful termination cases to determine if they want to move forward or not. Damages are lost wages and benefits past and future as well as any consequential damages such as lost savings, taking money from a 401k, borrowing money, ect.. Damages also must mitigated, meaning that if an individual obtains future employment their damages would be lost wages minus their current wages and benefits if any. There can also be an award for pain and suffering and a penalty fee against the company. That award amount varies depending on the size of the company and the max amount is $300,000 for the largest company and awards like these are typically rare and the conduct must be very severe. However, individuals may also have other causes of action outside of a discrimination claim related to the case where there would not be a limit on awards.

4. Time in litigating cases: We appreciate your time in filling out this form. We take our cases very seriously and work very hard for the causes of our clients. We are able to find a lot of claims that other attorneys may miss or not consider that can lead to a higher amount of damages for the case. Employment cases are very complex given the large amount of time-frame and facts involved and the different areas of law the case could involve with different avenues of entities to approach to seek recovery. Usually theses cases take a lot of time to resolve and can typically extend over a year. The firm cannot guarantee instant recovery based on the nature of litigation and the other side's willingness to compromise. Most companies have enough capital to not comprise which is why these cases can be so lengthy at times and it takes a lot of time and effort to put the case before a decision-maker if the company will not compromise prior. For this reason we do these questionnaire.

5. We require truthfulness in answering questions: All answers to the questionnaire must be made honestly and truthfully. We want to ensure we have all the evidence at the inception of the case and what additional evidence is needed to ensure the case runs more smoothly. It is the evidence exchange that bogs down these cases. We also hope that you will be forthright and honest in answering these questions. These answers will be protected. If there are issues with the case those can be worked out. However, if any surprises come up or any misrepresentations down the road as far as evidence, it can severely dismantle the case and undermine the time the firm has already made in the case. We only work with the truth. There is no need to prove your case to us. What you may think is a weakness in your case may not actually be a relevant issue, it could actually be a strength or it can be properly dealt with.

Also, in filling out the questionnaire, please do not think that answering a question a certain way such as a yes or no will ruin your case. Many of the questions are looking for all possible causes of action some of which you may not have considered yourself. We just need the honest facts and we will prove your case for you. We pride ourselves in following all the rules of the court, the laws and causes of action, the rules of professional conduct and other regulations. Strict obedience to the rules and laws is how we win. Disregarding, making excuses or skirting around the law may lead to instant results but in the long-run can ruin a case a reputation or a cause.

We believe in our clients and their cause and we fight for them and their right for redressibility or defense to the extent the bounds of the law allow us. We will send a follow-up e-mail which may have additional questions or call regarding your case or inform you of any conflict issues or let you know about your options. Again, we appreciate your time and attention to this matter and reaching out to us to resolve your legal matter.
Name *
Your answer
Address *
Your answer
Phone number *
Your answer
Do you text and or prefer texts?
Your answer
E-mail *
Your answer
Emergency contact number *
Your answer
Birthdate *
MM
/
DD
/
YYYY
Gender / Race / Religion / Ethnicity Disability if applicable
Your answer
Employer *
Your answer
Employer Address *
Your answer
Position *
Your answer
Time worked with company *
Your answer
Wages *
Your answer
Employment background, years worked with other companies, names, addresses, position, compensation, basis for leaving
Your answer
Does your position require any licesnes from state or federal or other entities? If so, please provide and provide if you are current the date of entry / expiration.
Your answer
Are you a citizen of the U.S.? If not, what is your legal status? (Attorney client privileged)
Your answer
Were you considered an exempt employee?
Did you have hiring / firing decisions?
Did you make budget decisions?
Did you work overtime as an exempt employee?
How many hours of overtime did you work?
Your answer
Were you terminated from your position?
If so, what date were you terminated?
Your answer
What was the reason for the termination if any?
Your answer
Did you sign a contract with the company?
Were you considered at-will?
Were you given any assurances about the length of your employment?
If so, please explain.
Your answer
If you were terminated, what are your concerns about the termination?
Your answer
How big is the company? ie How many employees work there?
Your answer
What industry and services / does your company provide?
Your answer
Are they a subsidiary or branch of a bigger entity or corporation / agency?
Your answer
Please explain your reason for reaching out to an attorney in regards to your legal concerns.
Your answer
Description of Evidence and Witnesses
What are the names of the individuals involved in this case? Please list their names and contact info if available.
Your answer
Please list all the names of individuals that would have information regarding this case including names and contact information if available.
Your answer
Do you have any documents, texts, e-mails, photos, videos, medical documents, voicemails, recorded messages ect. that relate to this? If so please describe what information they provide and provide the information.
Your answer
Please describe in detail the events that occurred if you are physically, emotionally able. This includes all events and their dates, where they occurred, who witnessed the events, what was said, what reactions were made, what occurred as a result, why it occurred, the basis and claims for their occurrence. Details are very important. The more detail here the better as this can be used as a statement for evidence later in the case.
Your answer
Did any individual make a false statement regarding your employment or regarding your character that was told to someone else beside yourself or published through e-mail, text, ect? If so, please explain the situation and how long ago it occurred.
Your answer
Did anyone make physical threats toward you and or physically hurt you? If so, please explain the dates and basis and how the situation was handled.
Your answer
Were there any promises made to you during your employment either verbal or written that were not fulfilled? If so, please explain and the dates and basis.
Your answer
Are there concerns about how the company treated other people the same as they treated you? If so please describe including persons involved.
Your answer
Were any injuries that occurred here as a result of a product owned by the company? If so, please describe the product, the company that manufactures it, why you were using it, if you were using it properly, if you were trained on it, if you were injured as a result of something you did not expect.
Your answer
If this a contract case or contract review, please describe what terms you feel were breached or what terms you want reviewed / revised. Please provide a copy of the contract.
Your answer
Please provide a copy of your paystubs and last two years of tax returns if applicable.
Your answer
If you do not have access to some information, to prove your or that relates to your case please provide a description of the evidence, and who would have it in their possession including names and addresses.
Your answer
Do you have concerns that some evidence has been destroyed or tainted? If so please describe.
Your answer
Discrimination based on a protected class or whistle-blower claims
If you think this was based off the basis of discrimination based off gender, race, disability or other protected class please describe why you feel so and who was involved.
Your answer
If this is a discrimination case, was the company on notice of the issues? Did they do anything to try and resolve the issues? Please describe how and the results.
Your answer
Did you report any issues of the company regarding discrimination, whistleblower issues, to anyone within the company or outside the company? If so, when and to what person, agency or company?
Your answer
Were you harassed based on a protected class or whistleblower issue were there multiple incidents? If it was one incident why do you think it was egregious? Please explain.
Your answer
Did you feel that the situation was so hostile you had no choice to leave the company or did you feel that the situation is or was hostile, if so, please explain why?
Your answer
Have you filed a claim for this case with the state or federal EEOC? Or with the EEOC agency if you are a federal employer? (For Discrimination)
Please explain were there process is if yes to the above answer.
Your answer
Have you filed a complaint with OSHA or an applicable state or federal agency? (Whistleblower cases?)
Did you ever ask for an accommodation? (Disability, religion, pregnancy ect).
Please explain were there process is if yes to the above answer.
Your answer
If you did and they failed do you think what you were asking for was reasonable? Why?
Your answer
Post-Termination and Employment Benefits Questions
Have you applied for unemployment?
Please explain the outcome or process if yes to the above answer.
Your answer
Have you obtained other employment if you have been terminated?
Were you denied any benefits, bonuses compensation or reimbursements while you worked with the company?
Please explain your job duties, what you did, hours worked, who you worked with, your position in relation to other positions, supervisors, managers.
Your answer
Did the company provide an employment handbook that you signed?
Please provide the employee handbook.
Are there concerns on how the situation was handled that goes against what is in the employee handbook? If so, please describe.
Your answer
Are there concerns on how the situation was handled compared to how other situations were handled and other people were treated? If so, please describe including persons involved.
Your answer
Did the company offer medical leave or Personal time off? If so, how was that handled? How much was offered? Was it ever denied at any time?
Your answer
Do you belong to a Union?
If so, please describe how the Union has handled this matter if you have reached out to them. Please provide their name, address and who you worked with.
Your answer
Does your company have a Human Resources department?
Did you know how to report a claim to them? Did you feel they were adequate / non-biased in handling claims and felt comfortable approaching them? How big was the department? Was there a place on site? Please explain.
Your answer
Are you on government assistance or applied for government assistance? Please provide dates and information related.
Your answer
Damages
What remedy are you seeking as a result of what occurred?
Your answer
Have you had to seek a therapist / physician / psychiatrist as a result of what has occurred and if so for what? Please also plan on making a record request for the visits as well as a record request for medical billing.
Your answer
Please list any additional issues you have suffered from. Also, please described in detail the factual reasons, including dates, where, when how these occurred as the best you can.
Your answer
Do you think you need to seek a medical attention as described above? If so, please explain.
Your answer
Were you denied a promotion or were you denied any outside or internal job offers or did you decide not to take on any job offers as a result of occurred? If so, please explain the facts, the position, the company, address, compensation amount ect. who was given the position if applicable, reason for denial, reason for turning down position.
Your answer
Did this cause problems to any pre-existing medical conditions? If so, please explain in details how and why including dates, times what occurred ect.
Your answer
Did your spouse turn down any job offers as a result of you taking on this job? If so, please explain. If your spouse works, please provide their position, company, condensation, time worked there. ect.
Your answer
Have you suffered from any of the following? Please check below.
Did you have any performance issues while with the company or with other companies? Please describe, dates, reasons basis. This includes talks with managers, counseling, suspensions, reprimands, leave without pay, fraud, abuse, ect.
Your answer
Have you incurred any expenses as a result of what has occurred ie, credit card debt, moving costs, saving accounts, pulling money from a 401k borrowing money from friends family. If so, please explain the amount, where the money and from who if applicable.
Your answer
Please provide the addresses and names of medical providers you have seen in the past 5 years. (If applicable with a disability, medical claims non-discrimination related including, pre-existing claims or workers compensation.
Your answer
Workers Compensation
Were you injured on the worksite? If so, what date, when did it occur? Witnesses? When was it reported? If not provided already.
Your answer
Was your compensation denied? If so, what date and what was the basis?
Your answer
Did you have an independant medical exam if your compensation claim? If so, what date. Please provide applicable information.
Your answer
How much has been paid to date on your Worker Compensation Claim?
Your answer
Are you still having issues with the injury? If so, please describe.
Your answer
Witnesses and Communication with company
Have you received any communication from the company regarding your case including but not limited to opposing counsel?
Please describe such communication if applicable and provide documents.
Your answer
Please list the names of witnesses and their addresses and contact information if available, that know about this case whether or not they are would hurt or help or testify against you and a quick summary of what information they would know about the case.
Your answer
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