Your Name
Job Title
Did you receive any additional pay beyond your regular hourly rate or salary (e.g., attendance bonuses, safety bonuses, commissions, etc.)? If yes, please describe the type of extra pay and how often you received it.
Please upload your paystubs for the past 12 months if they are available.
Position Type
full-time
part-time
seasonal
Shift worked
Day
Evening
Night
Rotating
Other
Please enter a value.
Remote / in-office / other
Remote In-office Hybrid Other
Please enter a value.
Employment Status
Full-time
Part-time
Please enter a value.
Reason you no longer work there
Layoff
Resignation
Discharge
Other
Please enter a value.
Have you had an interview with an adjudicator?
Yes No
Have you received a determination letter?
Yes
No
Are you receiving benefits?
Yes No
If you are not receiving benefits, have you appealed the determination?
Yes
No
Did your employer appeal your benefit eligibility?
Yes No Unsure
Have you received a Notice of Hearing?
Yes
No
Have you received an ALJ Decision?
Yes
No
Have you appealed the ALJ Decision?
Yes
No
Have you recieved a Board Decision?
Yes
No
Please click on one of the links below that addresses the issue raised in the determination letter from IDES:
Name of Employer
Location You Worked
Approximate Number of Employees
Your position and general job duties/responsibilities
Dates of Employment
Termination Information: (ONLY FILL THIS SECTION OUT IF YOUR EMPLOYER TERMINATED YOU) Discharge (602A)
Who terminated you?
Who was present at the termination meeting?
How was the termination communicated?
In person Phone Email Other
What reason did the employer provide?
Did the employer give you a termination letter?
Yes No
Did the letter cite misconduct or performance?
Misconduct Performance Not specified
Please describe what happened at the final incident
Were you given an opportunity to explain or defend yourself?
Yes No
Was the discharge based on violation of a company policy?
Yes No
If yes, what policy were you told you violated?
Were you aware of this policy prior to termination?
Yes No
Were you warned for similar conduct/behavior before? If yes, when were the prior warnings and what were they for? Please provide a short summary.
Do you agree with the reason given? If not, why do you believe you were really fired?
Did the employer follow progressive discipline?
Yes No Unsure
Did you know you were on a final warning?
Yes No
Did you willfully and deliberately violate the policy?
Yes No
Did your conduct cause actual harm to the employer?
Yes No
Was the policy consistently enforced with all employees?
Yes No Unsure
If terminated for performance
When did you first recognize you were not meeting expectations?
What training did the employer provide?
Did you request additional training/assistance? Did employer provide support?
Were you placed on a performance improvement plan (PIP)?
How long was the PIP?
Did you receive coaching or corrective actions? When?
Did you provide the employer with any reasoning as to why you were not meeting their expectations?
Did you ever meet expectations?
Yes No Sometimes
What caused the change in your performance or their changed expectations?
Voluntary Quit (601A) (ONLY FILL THIS OUT IF YOU QUIT)
Did you quit in lieu of discharge? If so, please answer the questions for Discharge.
Did you provide notice of resignation?
Yes No
How much notice?
Who did you notify of your resignation?
How did you notify the employer of your resignation?
What reason did you provide for your resignation?
Was there a change in duties/pay, unsafe conditions, medical reasons, harassment/discrimination, or domestic violence?
What was the final incident that led to your decision to quit?
Did you try to resolve the issue before quitting? Who/when/how?
Did you escalate to HR/leadership?
Did you request accommodation? Employer steps taken?
Were you offered different terms to stay?
Yes No
Did a physician say you couldn’t continue working?
Yes No
Did you inform employer & submit medical documentation?
Yes No
Did you exhaust FMLA or other leave?
Yes No
Do you have supporting documentation (emails, doctor’s notes, HR complaints, texts)?
Reasonable Assurance (612) (ONLY FILL OUT IF YOU WORKED FOR AN EDUCATIONAL INSTITUTION)
Were you working at an educational institution?
Yes No
Were you a 12-month or 9–10 month employee?
12-month 9–10 month
Reasonable expectation of returning after scheduled break?
Yes No
Offered a job for next academic year?
Yes No
Same/similar services as previous job?
Yes No
Pay rate same/similar?
Yes No
Have you signed a contract or received a letter of intent for the upcoming term?
Yes No
Were you specifically told you were not eligible to return in the fall?
Yes No
What reason was provided? By whom?
Able and Available (500C), Refusal of Work (603) and Student Status (500C4)
During the period under review, were you actively seeking work?
Yes No
What job titles/positions were you seeking?
Do you have experience in those areas?
Yes No
How were you searching for work?
How many positions did you apply to per week in a Sunday to Saturday format?
Minimum wage you were willing to accept
Did you have transportation?
Yes No
How far were you willing to travel?
Specific shift available to work?
Restrictions/limitations on type of work or hours
Did you receive any offers or interviews?
Were you employed by a staffing agency?
Yes No
If yes, did you contact them weekly? How?
Did you refuse any positions offered? Why?
Evidence of contacts (emails, texts, phone logs)
Were you able to accept work if offered?
Yes No
Were you in school?
Yes No
Did your course schedule interfere with accepting a job?
Additional Information to Help Represent You
Please provide a summary of why you are seeking legal representation.
Were you offered a severance?
Do you have a written employment contract?
Have you filed any complaints or charges with any government agencies?
Yes No
Are there any deadlines of which you are aware?
How much were you paid?
What method were you paid?
Hourly Salary
Were you injured at work?
Yes No
How many hours did you typically work each week?
Have you ever been paid additional amounts beyond your regular pay?
Yes No
Does your employer use any biometric data?
Yes No
Required to undergo a physical exam or asked about family medical history?
Yes No
Aware of anything illegal occurring at your job?
Yes No
Does your employer have government contracts or funding?
Yes No
If we can’t help, may we share your info with another firm?
Yes No
*Upload paystubs or other relevant documents.
