FMLA/CFRA 
Information Form

Depending on the time of day, etc. Mr. Johnston is often able to respond within minutes to inquiries made from this form.  Mr. Johnston only practices law in California.  For this reason, he can only respond to inquiries from individuals concerning employment that occurred within the state of California.

*Please note*   By submitting this form, you agree that that you are not forming an attorney-client relationship with the Johnston Law Firm or its attorneys, and that no one from this firm will take any action on your behalf until such time as you have signed a written agreement with our office. Additionally, while the Johnston Law Firm will make every effort to keep the information submitted on this form confidential, since it has not been provided as part of any attorney-client relationship, any information submitted on this form will not be given the legal protection accorded to confidential attorney-client communications. 

Please provide the following information:

First Name
Last Name
Occupation
City of Residence
State
E-mail
Phone

Are/Were You a Government Employee?   Yes No

Are/Were You a Union Employee? Yes No
 

During the employment which is the subject of this inquiry, were you suffering from a serious health condition? Yes No

If yes, please describe your serious health condition.

 

If you were not suffering yourself from such a condition, was one of your family members suffering from a serious health condition? Yes No

If yes, please describe your family member's serious health condition.

 

Have you been terminated?   Yes No

If not, do you think you are about to be?   Yes No Maybe


If terminated or about to be terminated, what reason did your employer give you, if any?

Do you think this reason given by the employer was false?  If so, please explain.

If you were terminated, what was the date of the termination?

If you haven't been terminated, do you think you are about to be?   Yes No

If so, please explain.

Have you resigned from your position? Yes No


If you resigned your employment, what was the last date you worked for this employer?

Are you currently out on medical or other type of leave from this employment? Yes No


If so, on what date did you start your leave?

If you believe you have been discriminated against because of either your serious health condition, or that of a family member, in a way not already discussed above, please explain. 

 

Name of Employer

Please list the approximate length of time you worked for this employer.

What is/was your job title with this employer?

Approximately how many employees work for this employer? 

Are, or were you working under a written contract with this employer? Yes No

Have you filed any type of claim with any agency about your claim(s)? Yes No

If so, please list the agency or agencies with whom you have filed, and the approximate filing date(s).

During the time you worked for this employer, were you ever denied on a regular basis at least one half hour meal break on days that you worked more than 5 hours?? Yes No


During the period of time you worked for this employer, were you ever denied on a regular basis at least one 10 minute rest break for each 4 hour period that you worked? Yes No

During the time you worked for this employer, did you ever work overtime hours without receiving overtime pay compensation? Yes No

If there is any additional information that you believe would be important for Mr. Johnston to know, please list it in the box below.



  

The Johnston Law Firm
515 S. Flower Street, 36th Floor
Los Angeles, California 90071
(213) 291-6977