Confidential Wage Theft Questionnaire
Please answer the following questions to help Towards Justice analyze your potential wage theft claims (free). After completing this questionnaire, Towards Justice will be in touch within two weeks.

Towards Justice
1410 High Street, Suite 300
Denver, CO 80218

Office: 720-441-2236
Fax: 303-957-2289
www.towardsjustice.org

Full Name
Your answer
What is your preferred language?
What is your phone number?
By providing your phone number you authorize Towards Justice to contact you by phone, leave a voicemail, or text message.
Your answer
What is your email address?
By providing your email address you authorize Towards Justice to contact you by email.
Your answer
What is your zip code?
Your answer
Please describe your workplace concern or experience with wage theft.
Your answer
How much money do you believe your employer owes you?
Your answer
What is your job title, tasks, duties, or position?
Your answer
Is it your responsibility to pay workers?
Describe your work schedule and estimate the number of hours you work each week.
Your answer
Are you given 30-minute lunch breaks?
Are you given 10-minute breaks every 4 hours?
Did you work overtime? *
Required
If you did work overtime, were you paid at least 1.5x your regular rate?
Who is your employer?
Please note names, addresses, phone numbers, and/or websites/social media.
Your answer
Between what dates did you work for this employer?
Your answer
Approximately how many workers total work for this employer?
Your answer
Do you have any of the following other employment concerns?
Would you like to get involved in fighting wage theft in your community?
What is your gender?
How do you identify?
After Towards Justice analyzes your claim, do we have your permission to share your information in order to connect you with an attorney or advocate in our network? *
Submit
Never submit passwords through Google Forms.
This form was created inside of Towardsjustice.org.