CONFIDENTIAL SEXUAL HARASSMENT INTAKE FORM

Please fill in the information requested. Your information is covered by attorney-client privilege. Do not share this information with anyone except your lawyer(s). Your information will be simultaneously sent to attorney Dennis Niermann and his paralegal Harrison Daman when you click on the send button at the end of this form. We will do our best to contact you on the same day we receive your completed and sent form. After filling out this form and emailing it via this menu, you may contact Dennis Niermann at (216) 375-2696 or via email at dennis@niermannlaw.com.

** Required Fields

 
I am a:
Woman
Man
LGBT
Provide Any Details:
1. Do you believe you have ever been subjected to sexual harassment while employed here?
Yes
Unsure
2. When was the most recent incident? Check all that apply
I am currently experiencing a sexual harassment problem
less than six months ago
more than six months ago
less than 6 years ago
provide dates on which you were sexually harassed
was the sexual harassment ongoing (pervasive)
was the sexual harassment on one specific date (severe)
3. Who harassed you? Check all that apply.
company owner/CEO
higher management official
supervisor
union official
co-worker
client(s), vendor(s), customer or other non-employees
other (specify below)
4. What was the nature of the harassment? Check all that apply.
unwelcome sexual relations
unwelcome sexual relations in exchange for not being fired
unwelcome sexual relations in exchange for promotion
unwelcome physical contact (touching, pinching, brushing against your body, criminal conduct, assault, battery, rape )
commenting about your appearance or body
obnoxious or unwanted telephone calls
obnoxious or unwanted letters or other correspondence
sexual propositions
sexually suggestive objects or photographs or pornographic videos displayed in the workplace
offensive jokes or innuendos
other (specify)
5. What was your response to the harassment? Check all that apply.
nothing
resolved the problem by talking to the harasser
left the job by quitting or demanding a transfer
complained to management in writing and nothing was done
complained to management verbally and nothing was done
complained to the personnel office
filed a grievance through the union
filed charges with the state anti-discrimination agency
filed discrimination charges with the federal Equal Employment Opportunity Commission
consulted an attorney and filed a lawsuit and am seeking a new attorney
other (specify)
6. Was any adverse action threatened or taken against you because you complained about the harassment or because you refused to submit to it?
No
Yes. Check all that apply.
denied promotion
denied salary increase
reprimanded
given a poor performance evaluation
involuntarily transferred
discharged
other (specify)
7. Do you have an employee handbook?
Yes
No
8. Were you given a copy of the employee handbook to keep?
Yes
No
9. Is there a formal procedure that your employer provides for a method of complaining about sexual harassment?
Yes
No
10. Are there signs posted at your place of work that give notice that federal law prevents discrimination including sexual-harassment?
Yes
No
11. How many people were employed by the company at the time you were sexually harassed?
1 to 3 including myself
4 to 14 including myself
15 to 99 including myself
Over 100
Over 300
Over 500
12. What was the outcome of your effort to stop the harassment?
13. Do you have any documents, photographs, text messages, saved voice mails or the like that will support or confirm any potential claim that you might bring? If so give a short description
14. Are you seeing a psychiatrist or a psychologist in connection with your being sexually harassed? If so, provide their name, address and phone number below: