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    EMPLOYMENT QUESTIONNAIRE

    Notes:

    • Tell us about your case as best you can by providing answers to the question below.
    • You will need to provide the information in answer to questions 1 to 11 and 34 to 39.
    • If you have been dismissed you also need to answer questions 12 to 19.
    • If you are being subjected to disciplinary action you need to answer questions 20 to 26.
    • If you consider that you have been discriminated against you will need to answer questions 27 to 29.
    • If you have other complaints (for example unpaid pay, bonuses or commission) you will need to provide details in answer to questions 30 to 33

    Title :
    First name(s)


    Surname
    Date of birth

    Email address

    Telephone number
    Your enquiry
    What is the name of your employer/former employer

    Date of commencement of employment

    Date of termination of employment (unless continuing)

    Salary

    Net £ per (month,week, etc)

    Gross £ per (month,week, etc)

    Benefits (please list)

    Dismissal

    Is your complaint about a dismissal?
    If Yes answer questons 13 to 19

    Did you resign or did your employer terminate your contract of employment?

    What was the reason given?

    Did you appeal?

    What do you say about the circumstances
    in which your employment ended?

    Have you since got another job?
    If yes, answer questions 18 to 19

    When did you start the job?

    How much to you earn?

    Gross £

    per

    (month,week, etc)

    Net £

    per

    (month,week, etc)

    Disciplinary action

    Are you being subjected to any disciplinary action?

    Describe the allegations against you

    What do you say about the allegations?

    Have you attended a disciplinary hearing?

    If yes, what was the outcome?

    Do you have any earlier disciplinary warnings on your record?

    If so, on what dates were they issued and what for (identify all)?

    Discrimination

    Do you consider that you have been discriminated against by reason of your sex, race, age or disability or other reason

    What is your characteristic which you consider has given rise to this discrimination? [e.g. sex – female, race – black African, age – in my 60s, disability – multiple sclerosis etc.]

    Describe in full what you consider to have constituted discrimination?

    Other complaints

    Are you owed any money by your employer? If so answer questions 31 to 32

    What are you owed the money for [e.g. wages, commission, expenses etc.]

    How much are you owed?
    £

    Describe here any additional complaints you have against your employer

    Grievance

    Have you submitted a grievance to your employer?

    Describe the outcome
    [If necessary, put “No outcome yet” if, for example, you are awaiting a grievance meeting]

    Existing employment tribunal proceedings

    Have you commenced any tribunal action in relation to the above?

    If so, on what date did you file your claim?

    Describe the stage that the proceedings have reached (specify the final hearing date if you have been notified of one)

    Legal expenses insurance

    Do you have legal expenses insurance as part of your insurance policy that you have (e.g. home buildings or contents policies).