Wage and Hour 
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.


If your primary claim involves nonpayment of overtime pay, please click here.

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
 

What is/was your job title with this employer?

Please describe your job duties in this position.

Did your employer deprive you of a 10 minute rest break or breaks  that you believe you were entitled to receive? Yes No

If yes, please list an approximate number of times your were denied a rest break or breaks or, if you were consistently denied rest breaks, please list the time period for which you were denied a rest break or breaks. 

Did your employer deprive you of a meal break or breaks that you believe you were entitled to receive? Yes No

If yes, please list an approximate number of times your were denied a meal break or breaks or, if you were consistently denied meal breaks, please list the time period for which you were denied a rest break or breaks. .

 
Did you ever complain to any state agency or public official about not receiving a rest or meal break?   Yes No

If yes, please list the agency and/or public official to whom you complained, and the dates each complaint was made.

Did you ever complain to your employer about not receiving a rest or meal break? Yes No
 

If yes, please list the supervisor or job superior to whom you complained, and the dates each complaint was made.

Was any adverse job action taken against you that you believe was in retaliation for complaining about not receiving a meal or rest break?  If so, briefly explain in the box below.

 

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?

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

Did you resign from your position? Yes No


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

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


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

Name of Employer

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

Approximately how many employees work for this employer? 

Are, or were you working under a written contract with this employer? 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